NUR 216 – EXAM 2 WITH CORRECTLY ANSWERED QUESTIONS GRADED A+
2026/NEWEST UPDATE!!!
Question 1
During a lower extremity assessment, a nurse observes that the client’s skin has a distinct brown
pigmentation around the ankles. Which of the following conditions is most likely indicated by
this finding?
A) Acute arterial occlusion
B) Arterial insufficiency
C) Venous insufficiency
D) Raynaud’s phenomenon
E) Cellulitis
Correct Answer: C) Venous insufficiency
Rationale: Brown pigmentation (hemosiderin staining) occurs when chronic venous
insufficiency causes red blood cells to leak out of the capillaries and into the tissues. As the
cells break down, they leave iron deposits that stain the skin brown.
Question 2
A client’s skin appears shiny and translucent, and the nurse notes a total absence of hair on the
lower legs. These findings are most characteristic of:
B) Venous insufficiency
B) Arterial insufficiency
C) Normal aging
D) Chronic dermatitis
E) Fluid volume excess
Correct Answer: B) Arterial insufficiency
Rationale: Shiny, translucent, and hairless skin are classic signs of impaired arterial blood
flow. When tissues do not receive adequate oxygenated blood, the skin thins and hair
follicles atrophy.
Question 3
Where is the most appropriate location for a nurse to assess skin turgor in an adult client?
A) The back of the hand
B) The abdomen
C) The forearm or sternum
D) The thigh
E) The forehead
Correct Answer: C) The forearm or sternum
Rationale: In adults, the back of the hand is often misleading due to a natural loss of
elasticity with age. The forearm or over the sternum provides a more accurate assessment
of hydration status.
Question 4
When assessing an infant for dehydration, the nurse should check skin turgor at which of the
, 2
following locations?
A) The sternum
B) The forearm
C) The abdomen
D) The heel
E) The scalp
Correct Answer: C) The abdomen
Rationale: For infants, the skin over the abdomen is the standard and most reliable location
for assessing turgor and hydration levels.
Question 5
A nurse notes that a client’s conjunctivae and nail beds appear significantly pale. This finding,
known as pallor, is most likely an indication of:
A) Hypoxia
B) Liver dysfunction
C) Localized vasodilation
D) Anemia or lack of blood flow
E) High blood pressure
Correct Answer: D) Anemia or lack of blood flow
Rationale: Pallor results from a decrease in hemoglobin or a lack of blood flow to the
surface. It is most easily detected in areas with thin skin or high vascularity, such as the
face, conjunctivae, and nail beds.
Question 6
A client with a dark skin tone is suspected of having cyanosis. Where is the most reliable
location for the nurse to detect this change?
A) The nail beds
B) The sclera
C) The palms of the hands
D) The hard palate
E) The earlobes
Correct Answer: D) The hard palate
Rationale: In individuals with dark skin tones, skin color changes can be difficult to see on
the surface. Cyanosis (a bluish tint indicating hypoxia) is best detected in the oral mucosa
and specifically the hard palate.
Question 7
The nurse observes a yellowish tint to a client’s sclera and mucous membranes. This is
documented as jaundice and suggests:
A) Impaired venous return
B) Liver dysfunction or RBC destruction
, 3
C) Localized inflammation
D) Chronic sun exposure
E) Iron deficiency
Correct Answer: B) Liver dysfunction or RBC destruction
Rationale: Jaundice is caused by an accumulation of bilirubin in the blood. This occurs
either because the liver is not processing it correctly (dysfunction) or because there is an
excessive breakdown of red blood cells (hemolysis).
Question 8
In a client with a light skin tone, where is jaundice typically detected first?
A) The nail beds
B) The palms of the hands
C) The oral mucous membranes
D) The forearms
E) The bridge of the nose
Correct Answer: C) The oral mucous membranes
Rationale: For light-skinned individuals, jaundice is most readily detected in the sclera and
the oral mucous membranes before it becomes visible on the rest of the skin.
Question 9
A nurse assesses a localized area of redness on a client’s sacrum that feels warm to the touch.
This erythema is most likely caused by:
A) Liver failure
B) Hypoxia
C) Localized vasodilation or inflammation
D) Endocrine disorders
E) Poor nutrition
Correct Answer: C) Localized vasodilation or inflammation
Rationale: Erythema is redness of the skin caused by increased blood flow (vasodilation) to
the area. It is a hallmark sign of inflammation, infection, trauma, or sun exposure.
Question 10
Which of the following findings is considered an "expected finding" during an assessment of the
fingernails?
A) A nail angle of 180 degrees
B) Capillary Refill Time (CRT) of 5 seconds
C) A nail angle of 160 degrees and firm bases
D) Brittle, peeling edges
E) Spongy nail bases
Correct Answer: C) A nail angle of 160 degrees and firm bases
2026/NEWEST UPDATE!!!
Question 1
During a lower extremity assessment, a nurse observes that the client’s skin has a distinct brown
pigmentation around the ankles. Which of the following conditions is most likely indicated by
this finding?
A) Acute arterial occlusion
B) Arterial insufficiency
C) Venous insufficiency
D) Raynaud’s phenomenon
E) Cellulitis
Correct Answer: C) Venous insufficiency
Rationale: Brown pigmentation (hemosiderin staining) occurs when chronic venous
insufficiency causes red blood cells to leak out of the capillaries and into the tissues. As the
cells break down, they leave iron deposits that stain the skin brown.
Question 2
A client’s skin appears shiny and translucent, and the nurse notes a total absence of hair on the
lower legs. These findings are most characteristic of:
B) Venous insufficiency
B) Arterial insufficiency
C) Normal aging
D) Chronic dermatitis
E) Fluid volume excess
Correct Answer: B) Arterial insufficiency
Rationale: Shiny, translucent, and hairless skin are classic signs of impaired arterial blood
flow. When tissues do not receive adequate oxygenated blood, the skin thins and hair
follicles atrophy.
Question 3
Where is the most appropriate location for a nurse to assess skin turgor in an adult client?
A) The back of the hand
B) The abdomen
C) The forearm or sternum
D) The thigh
E) The forehead
Correct Answer: C) The forearm or sternum
Rationale: In adults, the back of the hand is often misleading due to a natural loss of
elasticity with age. The forearm or over the sternum provides a more accurate assessment
of hydration status.
Question 4
When assessing an infant for dehydration, the nurse should check skin turgor at which of the
, 2
following locations?
A) The sternum
B) The forearm
C) The abdomen
D) The heel
E) The scalp
Correct Answer: C) The abdomen
Rationale: For infants, the skin over the abdomen is the standard and most reliable location
for assessing turgor and hydration levels.
Question 5
A nurse notes that a client’s conjunctivae and nail beds appear significantly pale. This finding,
known as pallor, is most likely an indication of:
A) Hypoxia
B) Liver dysfunction
C) Localized vasodilation
D) Anemia or lack of blood flow
E) High blood pressure
Correct Answer: D) Anemia or lack of blood flow
Rationale: Pallor results from a decrease in hemoglobin or a lack of blood flow to the
surface. It is most easily detected in areas with thin skin or high vascularity, such as the
face, conjunctivae, and nail beds.
Question 6
A client with a dark skin tone is suspected of having cyanosis. Where is the most reliable
location for the nurse to detect this change?
A) The nail beds
B) The sclera
C) The palms of the hands
D) The hard palate
E) The earlobes
Correct Answer: D) The hard palate
Rationale: In individuals with dark skin tones, skin color changes can be difficult to see on
the surface. Cyanosis (a bluish tint indicating hypoxia) is best detected in the oral mucosa
and specifically the hard palate.
Question 7
The nurse observes a yellowish tint to a client’s sclera and mucous membranes. This is
documented as jaundice and suggests:
A) Impaired venous return
B) Liver dysfunction or RBC destruction
, 3
C) Localized inflammation
D) Chronic sun exposure
E) Iron deficiency
Correct Answer: B) Liver dysfunction or RBC destruction
Rationale: Jaundice is caused by an accumulation of bilirubin in the blood. This occurs
either because the liver is not processing it correctly (dysfunction) or because there is an
excessive breakdown of red blood cells (hemolysis).
Question 8
In a client with a light skin tone, where is jaundice typically detected first?
A) The nail beds
B) The palms of the hands
C) The oral mucous membranes
D) The forearms
E) The bridge of the nose
Correct Answer: C) The oral mucous membranes
Rationale: For light-skinned individuals, jaundice is most readily detected in the sclera and
the oral mucous membranes before it becomes visible on the rest of the skin.
Question 9
A nurse assesses a localized area of redness on a client’s sacrum that feels warm to the touch.
This erythema is most likely caused by:
A) Liver failure
B) Hypoxia
C) Localized vasodilation or inflammation
D) Endocrine disorders
E) Poor nutrition
Correct Answer: C) Localized vasodilation or inflammation
Rationale: Erythema is redness of the skin caused by increased blood flow (vasodilation) to
the area. It is a hallmark sign of inflammation, infection, trauma, or sun exposure.
Question 10
Which of the following findings is considered an "expected finding" during an assessment of the
fingernails?
A) A nail angle of 180 degrees
B) Capillary Refill Time (CRT) of 5 seconds
C) A nail angle of 160 degrees and firm bases
D) Brittle, peeling edges
E) Spongy nail bases
Correct Answer: C) A nail angle of 160 degrees and firm bases
