NUR 216 – HEALTH ASSESSMENT EXAM 2 | QUESTIONS
AND ANSWERS | 2026 UPDATE | WITH COMPLETE
SOLUTIONS
• Brown pigmentation indicates -✓✓ venous insufficiency
• Shiny and translucent skin without hair indicates -✓✓ arterial insufficiency
• skin tugor locations -✓✓ adults-forearm or sternum
infant- abdomen
• pallor -✓✓ -loss of color: best noted in face, conjunctivae, nail beds, palms
-indication of anemia or lack of blood flow
• cyanosis -✓✓ Location- nail beds, sclera, MM
Changes for light skin tones best located in sclera
Changes for dark skin tones best located in hard palate
indication - hypoxia, or imapired venous return
• jaundice -✓✓ Location- sclera, skin, MM
Changes for light skin tones best detected in oral MM
Changes for dark skin tones best detected in hard palate
Indication- liver dysfunction, RBC destruction
• erythema -✓✓ Location- face, skin, trauma or pressure sore areas
Indication- inflammation, localized vasodilation, substance use, sun exposure, rash or
elevated body temperature
• Nails expectations -✓✓ firm bases and nail angles of 160 degrees
symmetrical nail beds with uniform color
CRT less than 3 seconds
• clubbing -✓✓ nails at an angle greater than 160, results from low oxygen saturations
related to heart or lung disease
• hair expectations -✓✓ symmetrical hair distribution
• alopecia -✓✓ results from endocrine disorders or poor nutrition
• hirsutism -✓✓ hair growth on the face shoulders or chest of a female that can results
from endocrine disorders
, • edema -✓✓ The accumulation of fluid in the tissues most often from direct trauma or
imparied venous return
Skin may appear tight and shiny
Assess the swelling for discoloration, location, and tenderness
Measure circumference in the extremities
Evaluate pity by compressing the skin for at least 5 seconds over a bony prominence,
the dept reflects the degree of edema
• edema rating -✓✓ 1+ trace, 2mm, rapid term
2+ mild, 4mm, 10-15 sec return
3+ moderate, 6mm, prolonged return
4+ severe, 8mm, prolonged term
• primary lesions arise -✓✓ from healthy skin tissue
• macule -✓✓ Nonpalpable, skin color change, smaller than 1cm
Freckle, petechiae
• papule -✓✓ Palpable, circumscribed, soiled elevation of the skin
Elevated nevus
• nodule -✓✓ Palpable, circumscribed, deep, dirm 1 to 2 CM
Wart
• vesicle -✓✓ Serous fluid filled smaller than 1 cm
Blister, herpes simplex, varicella
• pustule -✓✓ Pus filled, varies in size
Acne
• tumor -✓✓ Solid mass, deep, larger than 1 to 2 cm
Epithelioma
• wheal -✓✓ Palpable, irregular border, edematous
Insect bite
• secondary lesions result from -✓✓ a change in primary lesions
• erosion -✓✓ Loss of epidermis, moist surface, no bleeding
Ruptured vesicle
AND ANSWERS | 2026 UPDATE | WITH COMPLETE
SOLUTIONS
• Brown pigmentation indicates -✓✓ venous insufficiency
• Shiny and translucent skin without hair indicates -✓✓ arterial insufficiency
• skin tugor locations -✓✓ adults-forearm or sternum
infant- abdomen
• pallor -✓✓ -loss of color: best noted in face, conjunctivae, nail beds, palms
-indication of anemia or lack of blood flow
• cyanosis -✓✓ Location- nail beds, sclera, MM
Changes for light skin tones best located in sclera
Changes for dark skin tones best located in hard palate
indication - hypoxia, or imapired venous return
• jaundice -✓✓ Location- sclera, skin, MM
Changes for light skin tones best detected in oral MM
Changes for dark skin tones best detected in hard palate
Indication- liver dysfunction, RBC destruction
• erythema -✓✓ Location- face, skin, trauma or pressure sore areas
Indication- inflammation, localized vasodilation, substance use, sun exposure, rash or
elevated body temperature
• Nails expectations -✓✓ firm bases and nail angles of 160 degrees
symmetrical nail beds with uniform color
CRT less than 3 seconds
• clubbing -✓✓ nails at an angle greater than 160, results from low oxygen saturations
related to heart or lung disease
• hair expectations -✓✓ symmetrical hair distribution
• alopecia -✓✓ results from endocrine disorders or poor nutrition
• hirsutism -✓✓ hair growth on the face shoulders or chest of a female that can results
from endocrine disorders
, • edema -✓✓ The accumulation of fluid in the tissues most often from direct trauma or
imparied venous return
Skin may appear tight and shiny
Assess the swelling for discoloration, location, and tenderness
Measure circumference in the extremities
Evaluate pity by compressing the skin for at least 5 seconds over a bony prominence,
the dept reflects the degree of edema
• edema rating -✓✓ 1+ trace, 2mm, rapid term
2+ mild, 4mm, 10-15 sec return
3+ moderate, 6mm, prolonged return
4+ severe, 8mm, prolonged term
• primary lesions arise -✓✓ from healthy skin tissue
• macule -✓✓ Nonpalpable, skin color change, smaller than 1cm
Freckle, petechiae
• papule -✓✓ Palpable, circumscribed, soiled elevation of the skin
Elevated nevus
• nodule -✓✓ Palpable, circumscribed, deep, dirm 1 to 2 CM
Wart
• vesicle -✓✓ Serous fluid filled smaller than 1 cm
Blister, herpes simplex, varicella
• pustule -✓✓ Pus filled, varies in size
Acne
• tumor -✓✓ Solid mass, deep, larger than 1 to 2 cm
Epithelioma
• wheal -✓✓ Palpable, irregular border, edematous
Insect bite
• secondary lesions result from -✓✓ a change in primary lesions
• erosion -✓✓ Loss of epidermis, moist surface, no bleeding
Ruptured vesicle
