Skin
During a skin assessment, the nurse notes an irregularly shaped mole with multiple colors and a diameter of 7 mm. What is the nurse’s best action?
A. Document findings and reassess in 6 months
B. Apply topical corticosteroid
C. Refer the client for dermatologic evaluation
D. Cleanse with antiseptic and cover with dressing
Answer: C — Refer the client for dermatologic evaluation
Rationale:
This lesion meets the ABCDE criteria for possible melanoma (Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolution).
A/B/D delay necessary diagnostic intervention.
Which assessment finding requires immediate intervention?
A. Nail clubbing with angle >180°
B. Thickened yellow nails
C. Fine hair loss on lower legs
D. Pruritus after showering
Answer: A — Nail clubbing with angle >180°
Rationale:
Indicates chronic hypoxia (COPD, congenital heart disease).
B/C reflect chronic changes; D may indicate xerosis.
The nurse is caring for a patient with left-sided heart failure. Which finding best indicates pulmonary congestion?
A. Jugular vein distention
B. Bilateral inspiratory crackles
C. Dependent edema
D. Weight gain of 3 lb in 2 days
Answer: B — Bilateral inspiratory crackles
Rationale:
Left HF causes fluid backup into the lungs → crackles, dyspnea, orthopnea.
A/C/D indicate right-sided heart failure.
A patient reports calf pain when walking that subsides with rest. The nurse recognizes this as which condition?
A. Chronic venous insufficiency
B. Deep vein thrombosis (DVT)
C. Peripheral arterial disease (PAD)**
D. Lymphedema
Answer: C — Peripheral arterial disease (PAD)
Rationale:
Intermittent claudication (pain with exertion relieved by rest) = hallmark of PAD due to poor arterial perfusion.
A causes aching relieved by elevation; B = constant pain/swelling; D = nonpitting edema.
The nurse auscultates fine crackles in both lower lobes. Which condition is most consistent with this finding?
A. Asthma exacerbation
B. Chronic bronchitis
C. Pulmonary edema
D. Pneumothorax
Answer: C — Pulmonary edema
Rationale:
Fine crackles (rales) = alveolar fluid → seen in HF or pulmonary edema.
A = wheezes, B = coarse rhonchi, D = absent breath sounds.
A nurse is caring for a bedridden older adult. Which finding indicates the earliest stage of pressure injury?
A. Intact skin with non-blanchable redness
B. Partial-thickness loss with blister
C. Full-thickness tissue loss with visible fat
D. Exposed bone or tendon
Answer: A — Intact skin with non-blanchable redness
Rationale:
This is Stage I pressure injury.
B = Stage II, C = Stage III, D = Stage IV
Which finding is consistent with fungal nail infection (onychomycosis)?
A. Spoon-shaped nails
B. Thickened, yellow, brittle nails
C. Pitting and ridging of nails
D. Bluish discoloration
Answer: B — Thickened, yellow, brittle nails
Rationale:
Fungal infection leads to discoloration and brittleness.
A = iron deficiency; C = psoriasis; D = cyanosis.
The nurse correlates an S3 heart sound with which underlying process?
A. Ventricular noncompliance
B. Rapid filling of ventricles during early diastole
C. Atrial contraction against a stiff ventricle
D. Pulmonic valve stenosis
Answer: B — Rapid filling of ventricles during early diastole
Rationale:
S3 = "ventricular gallop" from fluid overload or decreased LV compliance (CHF).
A/C describe S4; D produces a murmur.
The nurse is assessing a patient with DVT. Which finding supports this diagnosis?
A. Cool, pale skin
B. Redness, warmth, and tenderness along a vein
C. Brown discoloration near ankles
D. Absent peripheral pulses
Answer: B — Redness, warmth, and tenderness along a vein
Rationale:
DVT causes inflammation of the vessel wall and localized pain/swelling.
A/C/D align more with arterial or chronic venous disease.
The nurse hears high-pitched musical sounds during expiration. What should the nurse suspect?
A. Pleural friction rub
B. Wheezes
C. Rhonchi
D. Crackles
Answer: B — Wheezes
Rationale:
Wheezes = narrowed airways (bronchospasm in asthma, COPD).
A = grating sound, C = coarse low-pitched, D = popping alveoli.
The nurse observes clubbing of the fingernails. What underlying condition is most likely?
A. Peripheral vascular disease
B. Chronic hypoxia from lung disease
C. Iron-deficiency anemia
D. Dehydration
Answer: B — Chronic hypoxia from lung disease
Rationale:
Clubbing results from prolonged low oxygenation (e.g., COPD, cyanotic heart disease).
A/C/D cause other nail changes (pallor, spoon nails, brittleness)
The nurse assesses a patient’s scalp and notes patchy hair loss with circular scaling lesions. What is the priority intervention?
A. Apply emollient
B. Administer antifungal treatment
C. Educate on hair hygiene
D. Notify infection control
Answer: B — Administer antifungal treatment
Rationale:
Tinea capitis (ringworm of scalp) is fungal; treated with antifungals.
A/C supportive; D unnecessary.
The nurse is teaching about preload. Which statement indicates correct understanding?
A. “Preload is the pressure the ventricle must overcome to eject blood.”
B. “Preload refers to the volume in the ventricles at the end of diastole.”
C. “Preload decreases when fluids are given.”
D. “Preload is controlled by the heart rate.”
Answer: B — Volume in the ventricles at the end of diastole
Rationale:
It represents ventricular stretch prior to contraction.
A defines afterload; C incorrect — fluids increase preload; D indirectly influences CO, not preload directly.
A patient with peripheral arterial disease states that leg pain occurs when sitting but eases when lying flat. What is the best nursing response?
A. “That’s expected; keep your legs elevated to relieve the pain.”
B. “Try dangling your legs when the pain occurs.”
C. “Apply ice packs to the painful area.”
D. “You may have venous insufficiency; avoid walking.”
Answer: B — ‘Try dangling your legs when the pain occurs.’
Rationale:
PAD pain relieved by dependency (gravity improves blood flow).
A elevates legs → worsens ischemia; C/D inappropriate.
A patient has O₂ saturation of 85% and cyanosis. Which nursing action is priority?
A. Encourage coughing and deep breathing
B. Reassess O₂ saturation in 15 minutes
C. Administer prescribed oxygen
D. Place patient in Trendelenburg position
Answer: C — Administer prescribed oxygen
Rationale:
Immediate intervention to correct hypoxemia.
A supportive, but not priority when SpO₂ <90%.
B/D delay or worsen oxygenation.
The nurse notes thin, shiny, hairless lower extremities. Which system should be further assessed?
A. Endocrine
B. Arterial circulation
C. Lymphatic
D. Venous circulation
Answer: B — Arterial circulation
Rationale:
Arterial insufficiency causes trophic skin changes: smooth, shiny skin and hair loss.
D causes brown discoloration and edema.
A patient has a pale, spoon-shaped nail bed (koilonychia). Which underlying condition should the nurse assess for?
A. Hyperthyroidism
B. Iron-deficiency anemia
C. Fungal infection
D. Vitamin B12 deficiency
B — Iron-deficiency anemia
Rationale:
Koilonychia (spoon nails) is caused by chronic hypoxia from anemia.
A, C, D cause other nail abnormalities.
Which physiologic mechanism contributes to the development of edema in heart failure?
A. Increased capillary oncotic pressure
B. Decreased hydrostatic pressure
C. Increased venous hydrostatic pressure and sodium retention
D. Lymphatic drainage enhancement
Answer: C — Increased venous hydrostatic pressure and sodium retention
Rationale:
Elevated venous pressure forces fluid into tissues; RAAS activation retains sodium/water.
A/B/D do not cause fluid accumulation.
The nurse identifies +3 pitting edema in both lower extremities. Which mechanism explains this finding?
A. Decreased capillary permeability
B. Increased oncotic pressure
C. Increased hydrostatic pressure
D. Decreased interstitial volume
Answer: C — Increased hydrostatic pressure
Rationale:
Venous congestion and right-sided HF ↑ capillary hydrostatic pressure → fluid leaks into interstitium.
A/B/D do not cause pitting edema.
The nurse hears low-pitched bubbling sounds over the bronchi. Which interpretation is correct?
A. Air moving through narrowed airways
B. Fluid or mucus in large airways
C. Collapsed alveoli reopening
D. Normal vesicular breath sounds
Answer: B — Fluid or mucus in large airways
Rationale:
Rhonchi = coarse, snoring sounds → mucus in bronchi.
A = wheezes, C = crackles, D normal in periphery.
A nurse documents a pressure injury as “partial-thickness dermal loss presenting as a blister.” What stage is this?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
Answer: B — Stage II
Rationale:
Stage II = shallow, open ulcer or intact blister.
Stage III involves subcutaneous fat, Stage IV exposes bone/tendon.
Which finding would be expected in an individual with chronic arterial insufficiency?
A. Ruddy brown skin and edema
B. Shiny, hairless skin with thickened nails
C. Warm, moist skin with bounding pulses
D. Pale, cool skin with dependent rubor and ulceration at ankles
Answer: B — Shiny, hairless skin with thickened nails
Rationale:
Arterial disease decreases O₂ and nutrient delivery → atrophy of skin and nails.
A = venous stasis, C/D partially correct but not nail-specific.
The nurse is teaching a patient about cardiac output (CO). Which statement shows correct understanding?
A. “Cardiac output is determined by the stroke volume divided by heart rate.”
B. “Cardiac output represents the blood pumped by each atrium per minute.”
C. “Cardiac output equals stroke volume multiplied by heart rate.”
D. “Cardiac output increases when afterload increases.”
Answer: C — CO = HR × SV
Rationale:
Normal CO = 4–8 L/min; determines tissue perfusion.
A/B/D are physiologically incorrect.
A patient with arterial insufficiency presents with a non-healing ulcer. Which description is most characteristic?
A. Irregularly shaped, moist wound near medial malleolus
B. Painless ulcer with brown drainage
C. Round, dry ulcer on lateral ankle or toes
D. Deep, foul-smelling wound with green drainage
Answer: C — Round, dry ulcer on lateral ankle or toes
Rationale:
Arterial ulcers = “punched-out,” dry, well-defined borders, distal location, very painful.
A/B = venous, D = infection, not specific to arterial etiology.
Which finding in a pneumonia patient indicates improvement?
A. Dullness on percussion
B. Productive cough with thick sputum
C. Decreased WBC count and clear breath sounds
D. Persistent tachypnea and hypoxia
Answer: C — Decreased WBC count and clear breath sounds
Rationale:
Resolution = improved gas exchange and reduced infection.
A/B/D indicate ongoing disease.