ATI RN
NCLEX Practice Questions Health Assessment Questions
Question 1 of 5
A patient has had a"terrible itch" for several months that he has been scratching continuously. On examination, the nurse might expect to find:
Correct Answer: D
Rationale: The correct answer is D: lichenification. Lichenification is the thickening and hardening of the skin due to chronic scratching or rubbing. In this case, the patient's continuous scratching has led to lichenification. The term "terrible itch" indicates a persistent and severe itching sensation, which aligns with the chronic scratching behavior.
Choices A, B, and C are not correct because a keloid is an overgrowth of scar tissue, a fissure is a small cut or crack in the skin, and keratosis is the thickening of the outer layer of the skin. These conditions are not directly related to chronic scratching behavior.
Question 2 of 5
The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS). Which of the following will the nurse most likely observe?
Correct Answer: C
Rationale: The correct answer is C: Erythematous scaly patch with sharp margins in the sacral area. In patients with AIDS, this presentation is most likely indicative of a common opportunistic infection called tinea corporis. This fungal infection often presents as erythematous scaly patches with well-defined borders. The location in the sacral area is also common due to the warm and moist environment.
Choice A, tinea capitis, is a fungal infection of the scalp and is not typically associated with AIDS.
Choice B describes a presentation more indicative of a condition like seborrheic dermatitis rather than an AIDS-related skin manifestation.
Choice D describes a presentation more typical of tinea corporis, which is not commonly seen in the axilla region in patients with AIDS.
Question 3 of 5
When performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices bilateral pitting edema in the lower legs. The skin is puffy and tight but of normal colour. There is no increased redness or tenderness, and the peripheral pulses are equal and strong. In this situation, which of the following is the most likely cause of the edema?
Correct Answer: A
Rationale: The correct answer is A: Heart failure. In this case, the most likely cause of the bilateral pitting edema in the lower legs is heart failure. The pitting edema along with the history of hypertension and coronary artery disease suggests fluid overload due to the heart's inability to pump effectively. The normal skin color, absence of redness or tenderness, and strong peripheral pulses indicate that the edema is not caused by venous thrombosis, local inflammation, or blockage of lymphatic drainage. In heart failure, fluid can accumulate in the lower extremities due to the heart's reduced ability to pump blood efficiently, leading to increased pressure in the veins and subsequent fluid leakage into the surrounding tissues.
Question 4 of 5
When assessing inflammation in a dark-skinned person, the nurse may need to:
Correct Answer: C
Rationale:
Step 1: Dark skin may not show cyanosis well, making choice A less reliable.
Step 2: Erythema refers to redness, which may not be easily visible in dark skin, making choice B less suitable.
Step 3: Palpating for edema and increased warmth allows for a more reliable assessment of inflammation in dark skin, making choice C the correct answer.
Step 4: Palpating for tenderness and ecchymosis may be useful but not specific to inflammation assessment in dark skin, making choice D less relevant.
Question 5 of 5
A semiconscious woman is brought to the emergency department after being found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red colour. The nurse suspects that this colouring is due to:
Correct Answer: B
Rationale: The bright cherry-red coloring in a semiconscious woman found on the floor in her kitchen indicates carbon monoxide poisoning. Carbon monoxide binds to hemoglobin with a higher affinity than oxygen, leading to tissue hypoxia and the characteristic cherry-red coloration. Polycythemia would result in a purplish-red color, carotenemia in a yellow-orange hue, and uremia in a pale or yellowish complexion.
Therefore, the correct answer is B, as it aligns with the clinical presentation and pathophysiology of carbon monoxide poisoning.