NUR 216 – HEALTH ASSESSMENT EXAM 2 QUESTIONS
COMPLETE WITH 100% VERIFIED ANSWERS AND
DETAILED RATIONALE
Question 1
A nurse is assessing a client's skin turgor. Which technique should the
nurse use to accurately evaluate this finding?
A) Pinching the skin on the forearm
B) Pressing firmly on the sternum
C) Palpating the skin temperature
D) Observing for skin discoloration
E) Measuring skin fold thickness
Correct Answer: A) Pinching the skin on the forearm
Rationale: Skin turgor is assessed by gently pinching the skin on the
forearm or sternum. Decreased turgor, where the skin remains tented,
indicates dehydration. The forearm is a standard site for this
assessment.
Question 2
A client presents with a lesion that has an irregular border, asymmetry,
and varying colors. The nurse should suspect which condition?
A) Seborrheic keratosis
B) Actinic keratosis
C) Malignant melanoma
D) Basal cell carcinoma
,E) Squamous cell carcinoma
Correct Answer: C) Malignant melanoma
Rationale: The ABCDE criteria for melanoma include Asymmetry, Border
irregularity, Color variation, Diameter greater than 6mm, and Evolving
or changing. This lesion displays classic warning signs of malignant
melanoma.
Question 3
Which structure is found in the epidermis layer of the skin?
A) Hair follicles
B) Sebaceous glands
C) Melanocytes
D) Sweat glands
E) Blood vessels
Correct Answer: C) Melanocytes
Rationale: Melanocytes are located in the basal layer of the epidermis.
They produce melanin, which gives skin its color and provides
protection against UV radiation. Hair follicles, glands, and blood vessels
are found in the dermis.
Question 4
The nurse is assessing an elderly client and notes decreased skin
elasticity and thinning. These changes are primarily due to:
A) Increased collagen production
B) Decreased sebaceous gland activity
C) Loss of subcutaneous fat and collagen
D) Increased melanocyte activity
E) Enhanced blood flow to the dermis
Correct Answer: C) Loss of subcutaneous fat and collagen
Rationale: Aging skin undergoes atrophy of the epidermis and dermis
,with loss of subcutaneous fat and collagen. This results in thinning skin,
decreased elasticity, and wrinkles. Sebaceous gland activity also
decreases but is not the primary cause of elasticity loss.
Question 5
A client has a wound that is healing by primary intention. The nurse
understands that this type of healing occurs when:
A) Wound edges are approximated and closed
B) The wound is left open to heal from the inside out
C) Granulation tissue fills the wound defect
D) The wound becomes infected before healing
E) Sutures are not used to close the wound
Correct Answer: A) Wound edges are approximated and closed
Rationale: Primary intention healing occurs when wound edges are
brought together with sutures, staples, or adhesive, and healing
proceeds with minimal tissue loss. This is typical of surgical incisions.
Question 6
The nurse notes a client has a stage 2 pressure injury. Which
characteristic best describes this wound?
A) Intact skin with non-blanchable redness
B) Full-thickness tissue loss with visible bone
C) Partial-thickness loss of dermis presenting as a shallow open ulcer
D) Full-thickness tissue loss with undermining
E) Non-blanchable redness over a bony prominence
Correct Answer: C) Partial-thickness loss of dermis presenting as a
shallow open ulcer
Rationale: Stage 2 pressure injuries involve partial-thickness loss of the
dermis, presenting as a shallow open ulcer with a red-pink wound bed
without slough. It may also present as an intact or ruptured blister.
, Question 7
An African American client's skin appears ashen or gray. The nurse
should assess this client for:
A) Jaundice
B) Anemia
C) Cyanosis
D) Erythema
E) Hyperthyroidism
Correct Answer: B) Anemia
Rationale: In dark-skinned individuals, anemia presents as an ashen,
gray, or dull appearance rather than the pallor seen in light-skinned
clients. This change in skin tone indicates decreased oxygenation and
should be further investigated.
Question 8
Which layer of the skin is primarily responsible for providing insulation
and cushioning?
A) Epidermis
B) Dermis
C) Hypodermis
D) Stratum corneum
E) Stratum germinativum
Correct Answer: C) Hypodermis
Rationale: The hypodermis, also called subcutaneous tissue, consists
primarily of adipose tissue that provides insulation, cushioning, and
energy storage. It is not considered part of the skin but attaches the
skin to underlying structures.
Question 9
A nurse is assessing a client with liver disease. The nurse observes
COMPLETE WITH 100% VERIFIED ANSWERS AND
DETAILED RATIONALE
Question 1
A nurse is assessing a client's skin turgor. Which technique should the
nurse use to accurately evaluate this finding?
A) Pinching the skin on the forearm
B) Pressing firmly on the sternum
C) Palpating the skin temperature
D) Observing for skin discoloration
E) Measuring skin fold thickness
Correct Answer: A) Pinching the skin on the forearm
Rationale: Skin turgor is assessed by gently pinching the skin on the
forearm or sternum. Decreased turgor, where the skin remains tented,
indicates dehydration. The forearm is a standard site for this
assessment.
Question 2
A client presents with a lesion that has an irregular border, asymmetry,
and varying colors. The nurse should suspect which condition?
A) Seborrheic keratosis
B) Actinic keratosis
C) Malignant melanoma
D) Basal cell carcinoma
,E) Squamous cell carcinoma
Correct Answer: C) Malignant melanoma
Rationale: The ABCDE criteria for melanoma include Asymmetry, Border
irregularity, Color variation, Diameter greater than 6mm, and Evolving
or changing. This lesion displays classic warning signs of malignant
melanoma.
Question 3
Which structure is found in the epidermis layer of the skin?
A) Hair follicles
B) Sebaceous glands
C) Melanocytes
D) Sweat glands
E) Blood vessels
Correct Answer: C) Melanocytes
Rationale: Melanocytes are located in the basal layer of the epidermis.
They produce melanin, which gives skin its color and provides
protection against UV radiation. Hair follicles, glands, and blood vessels
are found in the dermis.
Question 4
The nurse is assessing an elderly client and notes decreased skin
elasticity and thinning. These changes are primarily due to:
A) Increased collagen production
B) Decreased sebaceous gland activity
C) Loss of subcutaneous fat and collagen
D) Increased melanocyte activity
E) Enhanced blood flow to the dermis
Correct Answer: C) Loss of subcutaneous fat and collagen
Rationale: Aging skin undergoes atrophy of the epidermis and dermis
,with loss of subcutaneous fat and collagen. This results in thinning skin,
decreased elasticity, and wrinkles. Sebaceous gland activity also
decreases but is not the primary cause of elasticity loss.
Question 5
A client has a wound that is healing by primary intention. The nurse
understands that this type of healing occurs when:
A) Wound edges are approximated and closed
B) The wound is left open to heal from the inside out
C) Granulation tissue fills the wound defect
D) The wound becomes infected before healing
E) Sutures are not used to close the wound
Correct Answer: A) Wound edges are approximated and closed
Rationale: Primary intention healing occurs when wound edges are
brought together with sutures, staples, or adhesive, and healing
proceeds with minimal tissue loss. This is typical of surgical incisions.
Question 6
The nurse notes a client has a stage 2 pressure injury. Which
characteristic best describes this wound?
A) Intact skin with non-blanchable redness
B) Full-thickness tissue loss with visible bone
C) Partial-thickness loss of dermis presenting as a shallow open ulcer
D) Full-thickness tissue loss with undermining
E) Non-blanchable redness over a bony prominence
Correct Answer: C) Partial-thickness loss of dermis presenting as a
shallow open ulcer
Rationale: Stage 2 pressure injuries involve partial-thickness loss of the
dermis, presenting as a shallow open ulcer with a red-pink wound bed
without slough. It may also present as an intact or ruptured blister.
, Question 7
An African American client's skin appears ashen or gray. The nurse
should assess this client for:
A) Jaundice
B) Anemia
C) Cyanosis
D) Erythema
E) Hyperthyroidism
Correct Answer: B) Anemia
Rationale: In dark-skinned individuals, anemia presents as an ashen,
gray, or dull appearance rather than the pallor seen in light-skinned
clients. This change in skin tone indicates decreased oxygenation and
should be further investigated.
Question 8
Which layer of the skin is primarily responsible for providing insulation
and cushioning?
A) Epidermis
B) Dermis
C) Hypodermis
D) Stratum corneum
E) Stratum germinativum
Correct Answer: C) Hypodermis
Rationale: The hypodermis, also called subcutaneous tissue, consists
primarily of adipose tissue that provides insulation, cushioning, and
energy storage. It is not considered part of the skin but attaches the
skin to underlying structures.
Question 9
A nurse is assessing a client with liver disease. The nurse observes
