NR 222: Health Assessment & Promotion Final Exam complete Certification Prep and Advanced Study Guide: Detailed Topic Modules, Extensive Test Bank Review, Practice Questions, and Final Exam Readiness Manual

During an admission assessment, a patient reports experiencing burning chest discomfort after meals for the past three weeks. How should the nurse classify this information? A. Objective physical finding B. Subjective assessment data C. Confirmed diagnostic evidence D. Abnormal inspection finding Correct Answer: B. Subjective assessment data Rationale: The patient’s description of chest discomfort is subjective because it is reported by the patient and cannot be directly observed or measured by the nurse. Objective data include measurable or observable findings such as blood pressure, skin colour, or swelling. Question 2 A nurse observes that a patient’s skin is pale, cool, and moist and notes that the radial pulse is weak. How should these findings be classified? A. Subjective data because the patient must confirm them B. Objective data because the nurse directly observed or measured them C. Historical data because they describe a previous condition D. Unreliable data unless laboratory testing confirms them Correct Answer: B. Objective data because the nurse directly observed or measured them Rationale: Objective data are obtained through observation, inspection, palpation, percussion, auscultation, and measurement. Skin colour, temperature, moisture, and pulse strength can be assessed directly by the nurse. Question 3 Which findings should the nurse assess when performing a comprehensive skin examination? A. Colour, temperature, texture, turgor, oedema, and lesions B. Hearing acuity, pupil response, and facial symmetry C. Bowel sounds, abdominal contour, and organ size D. Joint stability, muscle strength, and gait pattern Correct Answer: A. Colour, temperature, texture, turgor, oedema, and lesions Rationale: A comprehensive skin assessment includes colour, temperature, texture or moisture, turgor, oedema, vascular changes, and lesions. The other options represent assessments of different body systems. Question 4 An older adult is being assessed for dehydration. Which site should the nurse use to obtain the most reliable assessment of skin turgor? A. The back of the hand B. The anterior shin C. The sternum or clavicular area D. The pad of the index finger Correct Answer: C. The sternum or clavicular area Rationale: The sternum or area beneath the clavicle is preferred in older adults because skin elasticity in these areas is less affected by ageing than the hands or extremities. Skin on the back of the hand may remain tented because of age-related changes. Question 5 Which skin finding would the nurse expect in a healthy adult who has been resting comfortably in a climate-controlled room? A. Cool and clammy B. Warm and dry C. Hot and excessively moist D. Cold with delayed capillary refill Correct Answer: B. Warm and dry Rationale: Normal skin is generally warm, dry, intact, and appropriate in colour for the patient’s pigmentation. Cool, clammy skin may occur with shock, anxiety, hypoglycaemia, or poor perfusion. Question 6 A patient experiencing severe respiratory distress develops bluish discoloration around the lips and nail beds. How should the nurse interpret this finding? A. Jaundice caused by bilirubin accumulation B. Cyanosis associated with inadequate oxygenation C. Erythema caused by increased superficial blood flow D. Pallor caused by excessive oxygen delivery Correct Answer: B. Cyanosis associated with inadequate oxygenation Rationale: Cyanosis is a bluish or grayish discoloration associated with increased deoxygenated haemoglobin and may indicate inadequate oxygenation or impaired circulation. Jaundice causes yellow discoloration, while erythema produces redness. Question 7 The nurse presses a patient’s fingernail until it blanches and observes that normal colour returns after four seconds. What is the most appropriate interpretation? A. Normal tissue perfusion B. Possible impaired peripheral perfusion C. Evidence of jaundice D. A normal finding in every adult Correct Answer: B. Possible impaired peripheral perfusion Rationale: Capillary refill provides a rapid assessment of peripheral perfusion. Colour generally returns promptly, often within approximately two seconds in adults. A four-second refill may indicate decreased circulation, hypothermia, dehydration, or cardiovascular compromise. Question 8 During a wound assessment, the nurse observes thick yellow-green drainage with an unpleasant odour. Which interpretation is most appropriate? A. Serous drainage associated with normal healing B. Sanguineous drainage caused by active bleeding C. Purulent drainage suggesting infection D. Clear drainage indicating a cerebrospinal fluid leak Correct Answer: C. Purulent drainage suggesting infection Rationale: Purulent drainage is commonly thick and may be yellow, green, tan, or brown, often with an offensive odour. It may contain white blood cells, microorganisms, and tissue debris and therefore suggests infection. Question 9 When palpating the temporomandibular joint, which finding should prompt additional assessment? A. Smooth movement without tenderness B. Symmetrical jaw opening C. Crepitus accompanied by locking D. Full movement without discomfort Correct Answer: C. Crepitus accompanied by locking Rationale: Crepitus, popping, pain, limited motion, or locking may indicate temporomandibular joint dysfunction or degenerative changes. Persistent crepitus with locking is abnormal and should be investigated. Question 10 A patient reports a new unilateral headache and scalp tenderness. Which temporal artery finding is most concerning? A. A smooth, nontender artery B. Symmetrical pulsations C. Tenderness and thickening D. A faint but palpable pulse Correct Answer: C. Tenderness and thickening Rationale: Temporal artery tenderness, thickening, reduced pulsation, or nodularity may indicate temporal arteritis, particularly when associated with a new headache, jaw pain, or visual changes. Prompt medical evaluation is required because untreated inflammation may cause vision loss.