,Exam 2 NSG121/NSG 121 Health Assessment |
Herzing (2026/2027) Verified Actual (PDF)
1. A nurse is preparing to perform a physical assessment on a client. Which sequence of techniques is
correct for the abdominal assessment?
A) Inspection, palpation, percussion, auscultation
B) Auscultation, inspection, palpation, percussion
C) Inspection, auscultation, percussion, palpation
D) Palpation, percussion, inspection, auscultation
Correct Answer: C) Inspection, auscultation, percussion, palpation
Rationale: The correct abdominal assessment sequence is inspection, auscultation, percussion, then
palpation. This order prevents altering bowel sounds before auscultation, which would occur if
palpation or percussion were performed first. Palpation and percussion can stimulate peristalsis,
making bowel sounds falsely active or altered.
2. A nurse is assessing a client's skin and notes a flat, non-palpable change in skin color that is less
than 1 cm in diameter. Which term best describes this lesion?
A) Papule
B) Macule
C) Nodule
D) Vesicle
Correct Answer: B) Macule
Rationale: A macule is a flat, non-palpable change in skin color, typically less than 1 cm in diameter,
such as a freckle or a petechia. A papule is a palpable, solid lesion less than 1 cm, a nodule is a larger
palpable lesion, and a vesicle is a fluid-filled blister. Differentiating primary lesions is fundamental to
accurate skin assessment.
,3. A nurse is teaching a client about the ABCDEs of melanoma. What does the "E" in this mnemonic
represent?
A) Elevation
B) Evolution
C) Erythema
D) Edema
Correct Answer: B) Evolution
Rationale: In the ABCDE mnemonic for melanoma, "E" stands for Evolution, which refers to any
change in the mole's size, shape, color, or symptoms such as itching or bleeding over time.
Asymmetry, Border irregularity, Color variation, and Diameter greater than 6 mm are the other
components.
4. A nurse is assessing a client's risk for skin cancer. Which factor presents the highest risk for
developing melanoma?
A) A history of severe sunburns during childhood
B) Living in a northern climate with less sun exposure
C) Having a dark skin complexion
D) Regular use of sunscreen with SPF 15
Correct Answer: A) A history of severe sunburns during childhood
Rationale: A history of severe, blistering sunburns, particularly in childhood or adolescence, is a
significant risk factor for melanoma. Living in a northern climate, having dark skin, and using
sunscreen are not risk factors; they are generally protective or neutral.
5. A nurse is assessing a client's skin turgor. Which technique should the nurse use?
A) Pinching a fold of skin on the client's sternum
B) Palpating the client's radial pulse
C) Observing the color of the client's nail beds
, D) Measuring the client's skin temperature
Correct Answer: A) Pinching a fold of skin on the client's sternum
Rationale: Skin turgor is assessed by gently pinching a fold of skin, typically on the sternum or the
back of the hand, and observing how quickly it returns to its normal position. Delayed return suggests
dehydration. The other options assess circulation, not turgor.
6. A nurse is assessing a client who has a large, raised, irregularly shaped lesion that is oozing
serosanguineous fluid. The nurse notes the lesion developed after a primary lesion was scratched. This
lesion is best classified as:
A) A primary lesion
B) A secondary lesion
C) A vascular lesion
D) A malignant lesion
Correct Answer: B) A secondary lesion
Rationale: Secondary lesions develop from primary lesions as a result of scratching, infection, or the
healing process. Examples include crusts, scales, erosions, and ulcers. Primary lesions arise from
previously normal skin. The description of oozing and development from a previous lesion indicates a
secondary change.
7. A nurse is assessing a client's burn injury. The wound is red, painful, and blisters upon palpation.
This burn is classified as:
A) Superficial (first-degree)
B) Superficial partial-thickness (second-degree)
C) Deep partial-thickness (second-degree)
D) Full-thickness (third-degree)
Correct Answer: B) Superficial partial-thickness (second-degree)
Herzing (2026/2027) Verified Actual (PDF)
1. A nurse is preparing to perform a physical assessment on a client. Which sequence of techniques is
correct for the abdominal assessment?
A) Inspection, palpation, percussion, auscultation
B) Auscultation, inspection, palpation, percussion
C) Inspection, auscultation, percussion, palpation
D) Palpation, percussion, inspection, auscultation
Correct Answer: C) Inspection, auscultation, percussion, palpation
Rationale: The correct abdominal assessment sequence is inspection, auscultation, percussion, then
palpation. This order prevents altering bowel sounds before auscultation, which would occur if
palpation or percussion were performed first. Palpation and percussion can stimulate peristalsis,
making bowel sounds falsely active or altered.
2. A nurse is assessing a client's skin and notes a flat, non-palpable change in skin color that is less
than 1 cm in diameter. Which term best describes this lesion?
A) Papule
B) Macule
C) Nodule
D) Vesicle
Correct Answer: B) Macule
Rationale: A macule is a flat, non-palpable change in skin color, typically less than 1 cm in diameter,
such as a freckle or a petechia. A papule is a palpable, solid lesion less than 1 cm, a nodule is a larger
palpable lesion, and a vesicle is a fluid-filled blister. Differentiating primary lesions is fundamental to
accurate skin assessment.
,3. A nurse is teaching a client about the ABCDEs of melanoma. What does the "E" in this mnemonic
represent?
A) Elevation
B) Evolution
C) Erythema
D) Edema
Correct Answer: B) Evolution
Rationale: In the ABCDE mnemonic for melanoma, "E" stands for Evolution, which refers to any
change in the mole's size, shape, color, or symptoms such as itching or bleeding over time.
Asymmetry, Border irregularity, Color variation, and Diameter greater than 6 mm are the other
components.
4. A nurse is assessing a client's risk for skin cancer. Which factor presents the highest risk for
developing melanoma?
A) A history of severe sunburns during childhood
B) Living in a northern climate with less sun exposure
C) Having a dark skin complexion
D) Regular use of sunscreen with SPF 15
Correct Answer: A) A history of severe sunburns during childhood
Rationale: A history of severe, blistering sunburns, particularly in childhood or adolescence, is a
significant risk factor for melanoma. Living in a northern climate, having dark skin, and using
sunscreen are not risk factors; they are generally protective or neutral.
5. A nurse is assessing a client's skin turgor. Which technique should the nurse use?
A) Pinching a fold of skin on the client's sternum
B) Palpating the client's radial pulse
C) Observing the color of the client's nail beds
, D) Measuring the client's skin temperature
Correct Answer: A) Pinching a fold of skin on the client's sternum
Rationale: Skin turgor is assessed by gently pinching a fold of skin, typically on the sternum or the
back of the hand, and observing how quickly it returns to its normal position. Delayed return suggests
dehydration. The other options assess circulation, not turgor.
6. A nurse is assessing a client who has a large, raised, irregularly shaped lesion that is oozing
serosanguineous fluid. The nurse notes the lesion developed after a primary lesion was scratched. This
lesion is best classified as:
A) A primary lesion
B) A secondary lesion
C) A vascular lesion
D) A malignant lesion
Correct Answer: B) A secondary lesion
Rationale: Secondary lesions develop from primary lesions as a result of scratching, infection, or the
healing process. Examples include crusts, scales, erosions, and ulcers. Primary lesions arise from
previously normal skin. The description of oozing and development from a previous lesion indicates a
secondary change.
7. A nurse is assessing a client's burn injury. The wound is red, painful, and blisters upon palpation.
This burn is classified as:
A) Superficial (first-degree)
B) Superficial partial-thickness (second-degree)
C) Deep partial-thickness (second-degree)
D) Full-thickness (third-degree)
Correct Answer: B) Superficial partial-thickness (second-degree)
