Which of the following findings is most concerning during a skin assessment?

Correct Answer: B

Rationale: The correct answer is B because a lesion that bleeds easily and does not heal could be indicative of skin cancer, such as melanoma. This finding is concerning as it suggests potential malignancy and requires immediate medical attention. A: A mole with uniform color and well-defined borders is typically considered benign and not as concerning during a skin assessment. C: A freckle that has not changed in size over several years is generally not worrisome as stable freckles are usually harmless. D: A birthmark present since infancy is usually harmless and not a cause for concern during a skin assessment.

Correct Answer: D

Rationale: The correct answer is D because tenderness in the right upper quadrant is a specific clinical finding that would typically be recorded in the 'assessment' portion of the clinical record. This information is objective and related to a physical examination finding, which is crucial for assessing the patient's condition. A, B, and C are incorrect because they are subjective observations or general statements that do not provide specific clinical assessment information. Option A describes the patient's overall appearance, B relates to the patient's subjective feeling, and C provides a vital sign measurement, all of which would typically be recorded in the 'subjective' or 'objective' portions of the clinical record.

Correct Answer: B

Rationale: The correct answer is B because it provides specific, measurable data (heart rate of 80 bpm) that is observable and quantifiable. Objective information is based on facts and observable phenomena, not subjective interpretations or feelings. Choices A, C, and D involve subjective statements from the patient, which can vary based on individual perception and interpretation, making them less reliable for making clinical decisions.

Correct Answer: C

Rationale: The high-pitched, tinkling sounds heard during auscultation of the abdomen indicate bowel obstruction. This is due to the increased peristalsis and fluid and gas moving through the obstructed bowel, causing the tinkling noise. Normal peristalsis (choice A) would not produce such sounds. Gastrointestinal reflux (choice B) is associated with heartburn and regurgitation, not tinkling sounds. Ascites (choice D) is the accumulation of fluid in the peritoneal cavity and would not produce the described tinkling sounds. In summary, the tinkling sounds suggest bowel obstruction due to increased peristalsis and fluid and gas movement, making choice C the correct answer.

Correct Answer: A

Rationale: The correct answer is A: Recent memory. By asking the patient to recall three words, the nurse is assessing the patient's ability to remember information that was just presented to them, which falls under recent memory. This test helps evaluate the patient's immediate memory function and can provide insights into cognitive impairments or memory deficits. Incorrect choices: B: Long-term memory - This choice is incorrect because the nurse is assessing the patient's ability to recall information presented in the immediate past, not from a long time ago. C: Abstract reasoning - This choice is incorrect as assessing abstract reasoning involves tasks that require logical thinking and problem-solving, not simply recalling words. D: Orientation - This choice is incorrect because orientation refers to awareness of person, place, time, and situation, which is not being tested by asking the patient to recall three words.