NRS 420 Exam 2 V2 | NRS 420 Health Assessment |
Actual Q&A with Rationale (NRS420 Exam 2) |
Grand Canyon University
1. When assessing a patient’s skin for potential melanoma, the nurse uses the ABCDE
mnemonic. Which of the following findings are characteristic of malignant melanoma? (Select
all that apply)
A. Asymmetry of the lesion
B. Borders that are irregular or poorly defined
C. Color variation within a single lesion
D. Diameter less than 2 millimeters
E. Evolving changes in size or shape
F. Flat, non-palpable surface
Correct Answer: A, B, C, E
Explanation: The ABCDE mnemonic stands for Asymmetry, Border irregularity, Color
variation, Diameter greater than 6mm, and Evolving. Any lesion showing these signs
requires further diagnostic investigation to rule out malignancy. Early detection is critical
for improving the prognosis of patients with skin cancer.
,2. A nurse is palpating the chest of a patient with suspected pneumonia and notes increased
tactile fremitus. This finding is most likely associated with which condition?
A. Pneumothorax
B. Consolidation of lung tissue
C. Pleural effusion
D. Obstructed bronchus
Correct Answer: B
Explanation: Tactile fremitus is increased when lung tissue becomes consolidated, such as
in pneumonia. Liquid or solid mass conducts vibrations better than air-filled spaces.
Conversely, conditions that put extra air or fluid between the lung and the chest wall, like
pneumothorax, will decrease vibrations.
3. The nurse is auscultating the heart sounds of an adult patient. Where is the best location to
hear the S1 heart sound?
A. Second right intercostal space
B. Second left intercostal space
C. Third left intercostal space
D. Fifth intercostal space at the left midclavicular line
Correct Answer: D
, Explanation: The S1 heart sound, produced by the closure of the atrioventricular valves, is
heard loudest at the apex of the heart. The apex is anatomically located at the fifth
intercostal space at the left midclavicular line. This site is also known as the mitral area or
the point of maximal impulse.
4. During an eye assessment, the nurse tests the pupillary light reflex. Which cranial nerve is
primarily responsible for the sensory component of this reflex?
A. Cranial Nerve II (Optic)
B. Cranial Nerve III (Oculomotor)
C. Cranial Nerve IV (Trochlear)
D. Cranial Nerve VI (Abducens)
Correct Answer: A
Explanation: The optic nerve (CN II) carries the sensory impulse of light from the retina to
the brain. The oculomotor nerve (CN III) then provides the motor response that causes the
pupil to constrict. This combined action ensures the eye can adjust to varying levels of light
intensity.
5. While assessing the neck, the nurse palpates the lymph nodes. Which characteristics of a
lymph node would be most concerning for malignancy?
A. Soft, mobile, and non-tender
B. Small, discrete, and rubbery
C. Firm, mobile, and tender
Actual Q&A with Rationale (NRS420 Exam 2) |
Grand Canyon University
1. When assessing a patient’s skin for potential melanoma, the nurse uses the ABCDE
mnemonic. Which of the following findings are characteristic of malignant melanoma? (Select
all that apply)
A. Asymmetry of the lesion
B. Borders that are irregular or poorly defined
C. Color variation within a single lesion
D. Diameter less than 2 millimeters
E. Evolving changes in size or shape
F. Flat, non-palpable surface
Correct Answer: A, B, C, E
Explanation: The ABCDE mnemonic stands for Asymmetry, Border irregularity, Color
variation, Diameter greater than 6mm, and Evolving. Any lesion showing these signs
requires further diagnostic investigation to rule out malignancy. Early detection is critical
for improving the prognosis of patients with skin cancer.
,2. A nurse is palpating the chest of a patient with suspected pneumonia and notes increased
tactile fremitus. This finding is most likely associated with which condition?
A. Pneumothorax
B. Consolidation of lung tissue
C. Pleural effusion
D. Obstructed bronchus
Correct Answer: B
Explanation: Tactile fremitus is increased when lung tissue becomes consolidated, such as
in pneumonia. Liquid or solid mass conducts vibrations better than air-filled spaces.
Conversely, conditions that put extra air or fluid between the lung and the chest wall, like
pneumothorax, will decrease vibrations.
3. The nurse is auscultating the heart sounds of an adult patient. Where is the best location to
hear the S1 heart sound?
A. Second right intercostal space
B. Second left intercostal space
C. Third left intercostal space
D. Fifth intercostal space at the left midclavicular line
Correct Answer: D
, Explanation: The S1 heart sound, produced by the closure of the atrioventricular valves, is
heard loudest at the apex of the heart. The apex is anatomically located at the fifth
intercostal space at the left midclavicular line. This site is also known as the mitral area or
the point of maximal impulse.
4. During an eye assessment, the nurse tests the pupillary light reflex. Which cranial nerve is
primarily responsible for the sensory component of this reflex?
A. Cranial Nerve II (Optic)
B. Cranial Nerve III (Oculomotor)
C. Cranial Nerve IV (Trochlear)
D. Cranial Nerve VI (Abducens)
Correct Answer: A
Explanation: The optic nerve (CN II) carries the sensory impulse of light from the retina to
the brain. The oculomotor nerve (CN III) then provides the motor response that causes the
pupil to constrict. This combined action ensures the eye can adjust to varying levels of light
intensity.
5. While assessing the neck, the nurse palpates the lymph nodes. Which characteristics of a
lymph node would be most concerning for malignancy?
A. Soft, mobile, and non-tender
B. Small, discrete, and rubbery
C. Firm, mobile, and tender
