NUR 216 – EXAM 2 COMPREHENSIVE REVIEW QUESTIONS
COMPLETE WITH 100% CORRECT ANSWERS
Question 1
A nurse is assessing a client's lower extremities and notes thick,
hardened skin with a "woody" texture. Which condition is most likely
indicated by this finding?
A) Arterial insufficiency
B) Venous insufficiency
C) Lymphedema
D) Cellulitis
Correct Answer: C) Lymphedema
Rationale: Lymphedema causes the skin to become thick, hardened,
and fibrotic with a "woody" or "peau d'orange" appearance due to the
accumulation of lymphatic fluid and subsequent tissue changes.
Question 2
During a skin assessment, a nurse observes a client's heels appear pale
and cool to the touch. Which finding is most consistent with this
presentation?
A) Venous stasis
B) Arterial insufficiency
C) Normal peripheral circulation
D) Superficial thrombophlebitis
Correct Answer: B) Arterial insufficiency
Rationale: Pale, cool extremities are classic signs of arterial insufficiency
,due to reduced blood flow. The pallor indicates decreased oxygenated
blood reaching the tissue.
Question 3
A nurse is preparing to assess skin turgor in an elderly client. Which
location would provide the most reliable assessment?
A) The back of the hand
B) The sternum
C) The forehead
D) The thigh
Correct Answer: B) The sternum
Rationale: In elderly clients, skin elasticity decreases throughout the
body. The sternum maintains better elasticity compared to the back of
the hand, which shows age-related changes more dramatically.
Question 4
A nurse assessing an infant's skin turgor tenting the skin on the
abdomen and noting it returns slowly. This finding most likely indicates:
A) Normal hydration status
B) Mild dehydration
C) Severe malnutrition
D) Fluid overload
Correct Answer: B) Mild dehydration
Rationale: Slow return of skin after tenting indicates decreased skin
elasticity due to fluid loss. In infants, this is an early sign of dehydration.
Question 5
A client presents with redness and warmth over the left calf. The nurse
suspects:
A) Arterial insufficiency
,B) Venous insufficiency
C) Inflammation or infection
D) Peripheral neuropathy
Correct Answer: C) Inflammation or infection
Rationale: Erythema (redness) and warmth are cardinal signs of
inflammation or infection caused by localized vasodilation and
increased blood flow to the affected area.
Question 6
During an integumentary assessment, a nurse notes a client's nail beds
are pale with a capillary refill time of 4 seconds. This finding indicates:
A) Normal circulation
B) Impaired arterial circulation
C) Venous congestion
D) Anemia
Correct Answer: B) Impaired arterial circulation
Rationale: Capillary refill time greater than 3 seconds indicates delayed
return of blood flow to the capillaries, suggesting impaired arterial
circulation.
Question 7
A nurse is assessing a client with dark skin and suspects cyanosis. Which
location is most appropriate for assessment?
A) The palms
B) The oral mucosa
C) The soles of the feet
D) The nail beds
Correct Answer: B) The oral mucosa
Rationale: In dark-skinned individuals, cyanosis is best detected in the
, oral mucosa, particularly the hard palate and conjunctiva, where
pigmentation is less likely to obscure color changes.
Question 8
A client's skin appears yellow-orange, but the sclera is white. This
finding is most consistent with:
A) Jaundice
B) Carotenemia
C) Hepatic failure
D) Hemolytic anemia
Correct Answer: B) Carotenemia
Rationale: Carotenemia causes yellow-orange skin discoloration without
scleral involvement, unlike jaundice which causes yellowing of both skin
and sclera.
Question 9
A nurse notes a client has developed petechiae on the lower
extremities. This finding is most likely associated with:
A) Liver disease
B) Low platelet count
C) Venous stasis
D) Arterial occlusion
Correct Answer: B) Low platelet count
Rationale: Petechiae are pinpoint hemorrhages caused by bleeding
from capillaries. They are commonly associated with thrombocytopenia
(low platelet count) and clotting disorders.
Question 10
A client's nails are concave with raised edges, described as spoon-
shaped. This finding is known as:
COMPLETE WITH 100% CORRECT ANSWERS
Question 1
A nurse is assessing a client's lower extremities and notes thick,
hardened skin with a "woody" texture. Which condition is most likely
indicated by this finding?
A) Arterial insufficiency
B) Venous insufficiency
C) Lymphedema
D) Cellulitis
Correct Answer: C) Lymphedema
Rationale: Lymphedema causes the skin to become thick, hardened,
and fibrotic with a "woody" or "peau d'orange" appearance due to the
accumulation of lymphatic fluid and subsequent tissue changes.
Question 2
During a skin assessment, a nurse observes a client's heels appear pale
and cool to the touch. Which finding is most consistent with this
presentation?
A) Venous stasis
B) Arterial insufficiency
C) Normal peripheral circulation
D) Superficial thrombophlebitis
Correct Answer: B) Arterial insufficiency
Rationale: Pale, cool extremities are classic signs of arterial insufficiency
,due to reduced blood flow. The pallor indicates decreased oxygenated
blood reaching the tissue.
Question 3
A nurse is preparing to assess skin turgor in an elderly client. Which
location would provide the most reliable assessment?
A) The back of the hand
B) The sternum
C) The forehead
D) The thigh
Correct Answer: B) The sternum
Rationale: In elderly clients, skin elasticity decreases throughout the
body. The sternum maintains better elasticity compared to the back of
the hand, which shows age-related changes more dramatically.
Question 4
A nurse assessing an infant's skin turgor tenting the skin on the
abdomen and noting it returns slowly. This finding most likely indicates:
A) Normal hydration status
B) Mild dehydration
C) Severe malnutrition
D) Fluid overload
Correct Answer: B) Mild dehydration
Rationale: Slow return of skin after tenting indicates decreased skin
elasticity due to fluid loss. In infants, this is an early sign of dehydration.
Question 5
A client presents with redness and warmth over the left calf. The nurse
suspects:
A) Arterial insufficiency
,B) Venous insufficiency
C) Inflammation or infection
D) Peripheral neuropathy
Correct Answer: C) Inflammation or infection
Rationale: Erythema (redness) and warmth are cardinal signs of
inflammation or infection caused by localized vasodilation and
increased blood flow to the affected area.
Question 6
During an integumentary assessment, a nurse notes a client's nail beds
are pale with a capillary refill time of 4 seconds. This finding indicates:
A) Normal circulation
B) Impaired arterial circulation
C) Venous congestion
D) Anemia
Correct Answer: B) Impaired arterial circulation
Rationale: Capillary refill time greater than 3 seconds indicates delayed
return of blood flow to the capillaries, suggesting impaired arterial
circulation.
Question 7
A nurse is assessing a client with dark skin and suspects cyanosis. Which
location is most appropriate for assessment?
A) The palms
B) The oral mucosa
C) The soles of the feet
D) The nail beds
Correct Answer: B) The oral mucosa
Rationale: In dark-skinned individuals, cyanosis is best detected in the
, oral mucosa, particularly the hard palate and conjunctiva, where
pigmentation is less likely to obscure color changes.
Question 8
A client's skin appears yellow-orange, but the sclera is white. This
finding is most consistent with:
A) Jaundice
B) Carotenemia
C) Hepatic failure
D) Hemolytic anemia
Correct Answer: B) Carotenemia
Rationale: Carotenemia causes yellow-orange skin discoloration without
scleral involvement, unlike jaundice which causes yellowing of both skin
and sclera.
Question 9
A nurse notes a client has developed petechiae on the lower
extremities. This finding is most likely associated with:
A) Liver disease
B) Low platelet count
C) Venous stasis
D) Arterial occlusion
Correct Answer: B) Low platelet count
Rationale: Petechiae are pinpoint hemorrhages caused by bleeding
from capillaries. They are commonly associated with thrombocytopenia
(low platelet count) and clotting disorders.
Question 10
A client's nails are concave with raised edges, described as spoon-
shaped. This finding is known as:
