Question

Which question(s) should the nurse ask to a patient concerned about a rash? (Select all that apply)

Answer 1

Correct Answers:

Where is the rash located and has it spread?
How has the rash affected your ability to function at work?
When did you notice the rash?

Rationale :

🔵 Asking about the location and spread of a rash helps determine the pattern, severity, and possible causes such as infection, allergy, or systemic illness.

🔵 Asking how the rash affects functioning assesses the impact on daily activities and helps prioritize care or urgency of treatment.

🔵 Asking when the rash started provides essential information about onset, progression, and potential triggers such as new medications, foods, chemicals, or infections.

🔵 These questions align with therapeutic communication, which focuses on open-ended, non-judgmental assessment.

🔵 They also support accurate diagnosis, ensuring the nurse collects objective data about the rash characteristics and timeline.

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Answer 2

Correct Answers:

Severe dehydration

Rationale :

🔹 Dehydration reduces intravascular and interstitial fluid, causing the skin to lose elasticity and recoil slowly when pinched.

🔹 Skin turgor directly reflects hydration status because extracellular fluid volume depletion makes the skin tent.

🔹 Older adults may show decreased turgor on the sternum, but dehydration still produces poor recoil even in younger individuals.

🔹 Loss of fluid in dehydration decreases dermal elasticity, making the skin feel dry and less pliable.

🔹 Severe dehydration also reduces perfusion, worsening the skin’s ability to maintain its normal bounce-back characteristic.

Severe obesity

🔹 Obesity stretches the skin but does not impair its elasticity or recoil.

🔹 Turgor changes are related to hydration—not body fat percentage.

Connective tissue disorders

🔹 These cause thick or tight skin, not the poor recoil seen in dehydration.

🔹 Turgor is unreliable in these patients and does not indicate hydration status.

Childhood growth spurts

🔹 Growth changes do not affect skin recoil.

🔹 Turgor remains normal unless dehydration is also present.

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Answer 3

Correct Answers:

5th ICS, LMCL (Intercostal space, left midclavicular line)

Rationale :

⭐ The mitral valve is best heard at the cardiac apex.

⭐ This location corresponds to the PMI where left-sided sounds are strongest.

⭐ S1 intensity is loudest here due to mitral valve closure.

⭐ The 5th ICS LMCL provides the clearest sound for mitral murmurs.

⭐ It aligns anatomically with the left ventricle, enhancing sound transmission.

2nd ICS RSB

⭐ This is the aortic area, not mitral.

⭐ Used to assess aortic stenosis.

Lower LSB

⭐ This corresponds to the tricuspid area.

⭐ Mitral sounds are too distant here.

2nd ICS LSB

⭐ This is the pulmonic listening point.

⭐ Mitral murmurs cannot be accurately identified from this site.

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Answer 4

Correct Answers:

Braden scale

Rationale :

💠 The Braden scale is the standard tool to assess pressure injury risk.

💠 It evaluates key factors such as moisture, mobility, activity, and nutrition.

💠 Lower Braden scores show higher risk, guiding prevention.

💠 It is evidence-based and used widely in clinical settings.

💠 Early Braden assessment supports prevention strategies that reduce skin breakdown.

Glasgow scale

💠 Measures neurological status, not skin risk.

💠 Used in trauma or LOC evaluation.

FLACC scale

💠 Designed to assess pediatric pain, not ulcers.

💠 Rates facial expression, cry, activity, etc.

Morse scale

💠 Identifies fall risk, not tissue injury.

💠 Based on gait, history of falls, and mobility.

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Answer 5

Correct Answers:

Thin, shiny skin with loss of hair

Rationale :

🔶 Chronic arterial insufficiency causes ischemia, leading to skin thinning.

🔶 Reduced blood flow produces shiny, smooth skin.

🔶 Hair follicles die from decreased oxygen supply, causing hair loss.

🔶 Long-term arterial disease weakens the dermal layer.

🔶 These changes reflect reduced nutrient perfusion over time.

Fast-healing blisters

🔶 Arterial insufficiency delays healing, not speeds it up.

🔶 Poor perfusion impairs recovery.

Thick, leathery skin

🔶 Seen in venous insufficiency, not arterial.

🔶 Caused by chronic venous congestion.

Brown discoloration

🔶 Typical in venous stasis from hemosiderin deposition.

🔶 Not associated with arterial disease.

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Answer 6

Correct Answers:

A decrease in bone density

Rationale :

🟣 Osteoporosis is defined as a loss of bone mineral density.

🟣 Bone resorption exceeds bone formation, weakening structure.

🟣 Low density increases risk of fractures, especially hip and spine.

🟣 The internal bone matrix becomes porous and fragile.

🟣 DEXA scan confirms the condition by showing reduced mass.

Overgrowth of bone

🟣 Represents osteophytes, not osteoporosis.

🟣 Common in osteoarthritis.

Painful joint from cartilage damage

🟣 Describes osteoarthritis, not low bone density.

🟣 Cartilage—not bone—is primarily affected.

Inflamed painful red joint

🟣 Indicates arthritis, often rheumatoid.

🟣 Osteoporosis does not cause inflammation.

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Answer 7

Correct Answers:

Perform the Phalen's test
Perform the Tinel's test

Rationale :

🟦 This test increases pressure on the median nerve, helping reproduce numbness or tingling.

🟦 The patient flexes both wrists at 90° for 60 seconds, provoking symptoms in carpal tunnel.

🟦 It identifies Paresthesias in the thumb, index, and middle fingers.

🟦 Positive Phalen’s sign indicates median nerve compression.

🟦 It is a well-validated maneuver for carpal tunnel diagnosis.

🟦 Perform the Tinel’s test Tinel’s test involves tapping over the median nerve at the wrist.

🟦 Tingling or “electric-shock” sensation indicates nerve irritation.

🟦 It helps confirm neuropathy associated with carpal tunnel.

🟦 A positive response indicates nerve compression at the carpal tunnel.

🟦 This test is commonly used with Phalen’s to increase diagnostic accuracy.

McMurray’s test

🟦 Used to evaluate meniscal tears, not wrist neuropathy.

🟦 Involves knee rotation, unrelated to the median nerve.

Avoid assessment

🟦 Carpal tunnel does not involve blood clots, so assessment is safe.

🟦 Avoiding assessment delays diagnosis.

Bulge sign

🟦 Used to assess knee effusion, not wrist issues.

🟦 Completely unrelated to nerve compression.

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Answer 8

Correct Answers:

Inspect and palpate the patient's spine as the patient bends over as if to touch their toes.

Rationale :

🔶 The Adams forward-bend test reveals asymmetry in spinal curvature.

🔶 Bending forward highlights rib hump or raised areas caused by rotation.

🔶 This position allows palpation for lateral deviation of the spine.

🔶 Nurses observe uneven shoulders, scapulae, or hips in this stance.

🔶 Early detection helps identify potential structural scoliosis.

Measure the spine in centimeters

🔶 Length measurement does not detect curvature.

🔶 Scoliosis assessment requires visual asymmetry inspection.

Stand against a wall

🔶 This may show posture differences but misses rotational deformities.

🔶 It is not a validated scoliosis screening method.

Rotate at hips

🔶 Rotation does not expose rib prominence, crucial for diagnosis.

🔶 This method can hide asymmetry, not reveal it.

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Answer 9

Correct Answers:

Normal

Rationale :

🟩 A 2+ pulse on the grading scale indicates a normal strength.

🟩 It reflects adequate perfusion and consistent arterial flow.

🟩 The pulse is palpable, not weak or bounding.

🟩 It matches standard assessment scoring (0–4+ scale).

🟩 Indicates the patient has expected hemodynamic status.

Bounding

🟩 Bounding pulses are graded 3+ or 4+, not 2+.

🟩 They indicate increased cardiac output or fluid volume.

Weak

🟩 A weak pulse is 1+, felt faintly.

🟩 Suggests potential hypoperfusion or vascular disease.

Absent

🟩 Graded 0, meaning no detectable pulse.

🟩 A medical emergency, unlike 2+.

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Answer 10

Correct Answers:

S3

Rationale :

🟣 S3 occurs after S2 in early diastole.

🟣 It reflects ventricular noncompliance or rapid filling.

🟣 Best heard at the apex using the bell of the stethoscope.

🟣 Does not vary with respiration.

🟣 Often associated with heart failure, fluid overload, or reduced ejection fraction.

Incorrect Options (🟣)

Split S2

🟣 Varies with respiration, unlike S3.

🟣 Heard best at the base, not apex.

Split S1

🟣 Rare and occurs at beginning of systole, not diastole.

🟣 Not associated with ventricular compliance..

S4

🟣 Occurs before S1 (late diastole).

🟣 Due to stiff ventricles from hypertension or ischemia.

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NR 414 EXAM 2 CHOICE FALL 2 2025

No.

1 :
Which question(s) should the nurse ask to a patient concerned about a rash? (Select all that apply)

2 :
Which condition is consistent with decreased skin turgor?

3 :
Where does the nurse place their stethoscope to auscultate a patient's mitral valve?

4 :
What should the nurse plan to use to assess a patient at risk of pressure injury (ulcer) development?

5 :
Which finding is consistent with atrophic skin changes that occur with chronic arterial insufficiency?

6 :
What is the definition of osteoporosis?

7 :
Which tests are used to assess for carpal tunnel syndrome? (Select all that apply)

8 :
How would the nurse assess for scoliosis?

9 :
The nurse is reviewing an assessment of a patient's peripheral pulses and notices the documentation states the radial pulses are "2+". The nurse recognizes this reading indicates what type of pulse?

10 :
What is the adventitious heart sound heard best at the apex, occurring in early diastole after S2, NOT changing with respiration, and may indicate decrease compliance of the ventricle?

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NR 414 EXAM 2 CHOICE FALL 2 2025

No.

1 : Which question(s) should the nurse ask to a patient concerned about a rash? (Select all that apply)

2 : Which condition is consistent with decreased skin turgor?

3 : Where does the nurse place their stethoscope to auscultate a patient's mitral valve?

4 : What should the nurse plan to use to assess a patient at risk of pressure injury (ulcer) development?

5 : Which finding is consistent with atrophic skin changes that occur with chronic arterial insufficiency?

6 : What is the definition of osteoporosis?

7 : Which tests are used to assess for carpal tunnel syndrome? (Select all that apply)

8 : How would the nurse assess for scoliosis?

9 : The nurse is reviewing an assessment of a patient's peripheral pulses and notices the documentation states the radial pulses are "2+". The nurse recognizes this reading indicates what type of pulse?

10 : What is the adventitious heart sound heard best at the apex, occurring in early diastole after S2, NOT changing with respiration, and may indicate decrease compliance of the ventricle?

1 :
Which question(s) should the nurse ask to a patient concerned about a rash? (Select all that apply)

2 :
Which condition is consistent with decreased skin turgor?

3 :
Where does the nurse place their stethoscope to auscultate a patient's mitral valve?

4 :
What should the nurse plan to use to assess a patient at risk of pressure injury (ulcer) development?

5 :
Which finding is consistent with atrophic skin changes that occur with chronic arterial insufficiency?

6 :
What is the definition of osteoporosis?

7 :
Which tests are used to assess for carpal tunnel syndrome? (Select all that apply)

8 :
How would the nurse assess for scoliosis?

9 :
The nurse is reviewing an assessment of a patient's peripheral pulses and notices the documentation states the radial pulses are "2+". The nurse recognizes this reading indicates what type of pulse?

10 :
What is the adventitious heart sound heard best at the apex, occurring in early diastole after S2, NOT changing with respiration, and may indicate decrease compliance of the ventricle?