NR-302 Health Assessment I - Set 3 - Part 2

Correct Answer: It identifies clients needing fuller assessment

Screening is a short validated step that flags who is at risk, and a positive result triggers a full assessment and a dietitian referral. Inpatients are screened within a day of admission. Option a is incorrect because diagnosis rests on clinical characteristics gathered over a fuller evaluation, such as intake, weight change, muscle and fat loss, fluid accumulation and grip strength. A screen only sorts risk. Option b is incorrect because the two steps sit in sequence rather than substituting for one another. Screening comes first and is deliberately brief, while assessment follows for anyone the screen marks as at risk. Option c is incorrect because calculating protein requirements is dietitian work that follows referral and depends on weight, illness and organ function. Nothing on a short admission screen produces a gram target.

Correct Answer: Zosteriform, following a single unilateral dermatome

Vesicles grouped along one unilateral nerve route that halt at the midline are zosteriform, the signature of herpes zoster. The days of pain preceding the eruption fit reactivated varicella-zoster virus. Option a is incorrect because an annular lesion is circular, starting centrally and spreading outward to leave a clear middle inside an active ring. Tinea corporis makes that shape, not a dermatomal band. Option c is incorrect because confluent describes lesions that run together into one large area, the way hives merge across the trunk. The vesicles here stay in discrete clusters along a nerve. Option d is incorrect because polycyclic means several annular lesions have grown into one another, producing scalloped overlapping rings seen in psoriasis and lichen planus. No rings appear anywhere on this chest.

Correct Answer: Administer the prescribed analgesic without delay

Long standing pain lets the autonomic response habituate and the pain behaviors fade, so normal readings and laughter prove nothing. The report stands on its own, and the ordered medication is given. Option a is incorrect because charting the opposite of what the client said turns an observation into an accusation. That entry travels through the record and shapes how every later clinician approaches this person. Option b is incorrect because delaying for a quieter moment treats social behavior as a test the client must fail before relief arrives. Distraction closes the pain gate temporarily; it does not remove the pain. Option c is incorrect because a mismatch between appearance and score is a hallmark of adapted chronic pain, not evidence of misuse. Labeling a client this way is a bias that reliably produces undertreatment.

Correct Answer: Provocative and palliative factors

The letter P in the mnemonic carries two halves: what provokes the pain and what palliates it. Asking only about triggers loses the relief half, which shapes the plan of care. Option a is incorrect because region and radiation ask where the pain sits and whether it travels, which is answered by pointing rather than by describing triggers. Referral patterns come from that question instead. Option c is incorrect because severity captures intensity now, at worst, and at best, plus what the pain has stopped the client doing. Neither half of this nurse's question asks about magnitude. Option d is incorrect because timing covers when the pain began, how long each episode lasts, and how often it returns. A client answering this nurse names activities, not clock hours or frequency.

Correct Answer: Inflammation lowers albumin regardless of intake

Albumin falls during infection, injury and surgery because the liver shifts production toward inflammatory proteins. The low value marks illness severity and nutrition risk rather than proving anything about what the client ate. Option b is incorrect because national nutrition standards exclude albumin from the criteria used to diagnose malnutrition. Weight change, intake, muscle and fat loss, fluid accumulation and grip strength carry that decision instead. Option c is incorrect because albumin turns over slowly, with a half life of roughly three weeks, so it lags well behind any change in eating. Prealbumin moves faster but is confounded the same way. Option d is incorrect because a value inside the reference range offers no reassurance at all. Well nourished appearing numbers occur in clients who are clearly wasted, which is why the marker fails as a test.

Correct Answer: It is recorded as a deep tissue injury

Persistent non-blanchable maroon or purple discolouration under intact skin is a deep tissue pressure injury. No number is given, because the depth of damage below unbroken skin cannot be determined by inspection. Option a is incorrect because the first stage covers non-blanchable erythema, ordinary redness of intact skin. Deep red, maroon, or purple colour signals damage that began at the bone and muscle interface instead. Option b is incorrect because a second stage wound must show exposed dermis, whether as an open shallow area or a ruptured serum blister. This heel surface has not broken at all. Option d is incorrect because waiting delays care. Such injuries may resolve without any tissue loss or deteriorate to full-thickness damage within days, so documentation and pressure relief start now rather than later.

Correct Answer: State that pain relief is the nurse's job

Clients who fear being a bother underreport, so the nurse says plainly that managing pain is part of the job and then offers relief proactively at set intervals rather than waiting to be asked. Option a is incorrect because promising a calmer shift says nothing about her pain and leaves the belief untouched. She will still weigh her request against how busy the unit looks tomorrow. Option c is incorrect because putting the burden of asking back on a client who already hesitates guarantees late reporting. Pain reported only once it is severe takes longer and more medication to bring down. Option d is incorrect because ranking her behind other clients confirms exactly what she feared and teaches her to stay silent. Nothing in the scenario suggests a competing emergency that outranks treating this pain.

Correct Answer: Nerve pain responds poorly to opioid drugs

Pain from a damaged nerve answers poorly to opioids, so a limited response here is expected rather than a nursing error. The nurse reports it so an anticonvulsant, an antidepressant, or a topical agent can be added. Option a is incorrect because doubting the report is the most common and most damaging clinician barrier. Shingles pain is notoriously severe, and the descriptors given match nerve injury precisely rather than suggesting invention. Option b is incorrect because nerve pain is routinely invisible on scans and laboratory panels. Having nothing to see is a defining feature of this mechanism and a major reason such clients are undertreated. Option c is incorrect because the scenario states the drug was given an hour earlier. Assuming a missed dose sends the nurse hunting an administration problem while the real issue is a mismatch between drug and mechanism.

Correct Answer: Too little hemoglobin remains to turn visibly dark

Visible cyanosis needs roughly five grams per deciliter of deoxygenated hemoglobin in the capillaries. A severely anemic client can be dangerously hypoxemic with too little hemoglobin present to produce that dusky color. Option b is incorrect because a saturation in the eighties confirms that arterial oxygen has fallen well below normal. Low red cell mass worsens delivery to tissue, and it never protects the arterial value. Option c is incorrect because lips, tongue, and nail beds are chosen precisely for their lack of heavy pigment. Concealment cannot explain a finding at sites selected because they display color changes readily. Option d is incorrect because peripheral cyanosis does favor hands, feet, ears, and nose, while central cyanosis shows in lips, tongue, and mucosa. Neither pattern skips the mouth in a hypoxemic client.

Correct Answer: Iron is deficient

Spoon shaped nails, known as koilonychia, together with pallor of the conjunctivae and nail beds are the classic surface signs of iron deficiency, and heavy menstrual loss is the common cause in this client. Option a is incorrect because vitamin A shortage announces itself in the eyes first, with difficulty seeing at dusk, dry conjunctivae and foamy grey plaques. Nail shape stays normal and the nails do not hollow. Option b is incorrect because scurvy produces swollen bleeding gums, pinpoint hemorrhages around hair follicles and wounds that will not close. Those bleeding features are absent here, and heavy periods point elsewhere entirely. Option d is incorrect because low vitamin D shows up in bone, causing bone pain, proximal muscle weakness and, in children, bowed legs. It does not change nail contour or conjunctival color.

Correct Answer: A shortage of riboflavin

Cracking at the mouth corners together with a magenta tongue and seborrheic scaling around the nose is the riboflavin pattern, and chronic alcohol use depletes this and several other B vitamins. Option a is incorrect because scurvy centers on collagen failure, so the gums swell and bleed and small hemorrhages ring the hair follicles. Neither the magenta tongue nor the nasal scaling belongs there. Option c is incorrect because vitamin D governs bone mineralization, so its absence gives bone pain and weak hip and shoulder muscles in adults. Mouth and tongue findings are not part of that syndrome. Option d is incorrect because too little iodine enlarges the thyroid and slows metabolism, producing goiter, cold intolerance and fatigue. Lip fissures and a magenta tongue would not appear from that shortage.

Correct Answer: Expect an exaggerated burn from ordinary sun exposure

Tetracyclines such as doxycycline sensitise the skin, so a short time outdoors produces a burn far worse than the client expects. Sun avoidance, protective clothing, and diligent sunscreen use are taught before the exposure happens. Option b is incorrect because ultraviolet light passes through cloud cover and bounces off water, sand, and concrete. Timing doses around the weather gives false confidence and does nothing to change how the drug alters skin sensitivity. Option c is incorrect because one morning application wears off long before a day at the lake ends. Broad spectrum sunscreen needs reapplying at least every two hours and after swimming or heavy sweating. Option d is incorrect because freckles are benign clusters of pigment and carry no warning about drug reactions. Clients should never abandon a prescribed antibiotic course over a normal pigment finding without speaking to the prescriber.

Correct Answer: Report the loss and arrange a dietitian referral

Unintended loss of this size over three months clears the threshold for significant depletion, and painful dentures name a fixable cause. The finding is reported and a dietitian referral is arranged promptly. Option a is incorrect because unintended weight loss is never a normal feature of aging and always has a cause worth finding. Reassurance here closes off the search before anything has been examined. Option b is incorrect because waiting a year allows depletion to deepen while a painful denture keeps intake low. Nutritional decline is far easier to prevent than to reverse, so the delay itself causes harm. Option c is incorrect because a supplement does nothing about the mouth pain that is limiting what he can chew. Treating the barrier comes first, and calories, not vitamins, are what he is missing.

Correct Answer: Remove shoes and align the heels and shoulders

Standing height is taken without shoes, with heels, buttocks and shoulders touching the measure and the eyes looking straight ahead, because footwear and a tipped head both add false inches. Option a is incorrect because shoe soles add height that varies from visit to visit, so serial measurements stop being comparable. Stability is better managed by steadying the client than by keeping footwear on. Option b is incorrect because tipping the chin up extends the neck and lifts the crown of the head, inflating the reading. The gaze should stay level and directed straight forward instead. Option d is incorrect because seated measurement is reserved for clients who cannot stand, and recumbent length, knee height or arm span are then recorded with the method named. Switching methods invents a false change.

Correct Answer: Screen using other words and assess function

Many clients deny pain yet endorse aching, soreness, or discomfort, so screening with several words uncovers what one word misses. Asking whether the client can cough, turn, and walk supplies the functional evidence. Option a is incorrect because a quiet client is not automatically a comfortable one. Recording an absence of pain closes the assessment at the exact moment the nurse has reason to look harder. Option b is incorrect because culture shapes how suffering is expressed, never how much a nerve fires. Turning a generalization about a group into a fact about this person is precisely how undertreatment happens. Option c is incorrect because family members filter and soften what they pass along, and some hold firm views about medication. Relatives supply useful background, yet they cannot stand in for the client's own account.

Correct Answer: The neonatal infant pain scale

That newborn scale was designed for procedural pain and scores facial expression, cry, breathing pattern, arms, legs, and arousal state before, during, and after the stick. Higher totals signal the need for comfort measures. Option a is incorrect because choosing a word such as mild, moderate, or severe requires language the newborn does not have. Word lists suit older adults who dislike numbers, not infants undergoing a procedure. Option b is incorrect because pointing at a drawing begins around age three, once a child grasps that a picture stands for a feeling. A newborn cannot make that selection at all. Option d is incorrect because that instrument was developed and tested in older adults whose dementia has taken away speech. Its breathing and consolability items were never calibrated against newborn behavior during a painful procedure.

Correct Answer: Apply the same structured tool to every client

Structure is what limits the influence of implicit bias. Using a validated instrument the same way for every client, and auditing whose reports get charted with qualifiers, changes practice in a way resolve alone does not. Option b is incorrect because bias operates below awareness, so meaning well leaves it fully intact. Research on pain treatment shows disparities persisting among clinicians who sincerely believe they treat everyone identically. Option c is incorrect because tying medication to visible behavior rebuilds the very filter she is trying to remove. Stoic clients, adapted chronic pain clients, and those masking distress would all be pushed further back. Option d is incorrect because handing judgment to a colleague still makes the client prove pain to somebody. Assessment and advocacy belong to the nurse at the bedside, and escalating unrelieved pain is a responsibility rather than an option.

Correct Answer: The dermis and its connective tissue

The dermis is the inner supportive layer of collagen and elastic tissue, and it carries the nerves, sensory receptors, blood vessels, lymphatics, hair follicles, and glands, so injury reaching it bleeds and scars. Option a is incorrect because the epidermis has no blood supply of its own and is fed by diffusion from dermal capillaries. Its cells are keratinocytes and melanocytes, so a scrape confined to it does not bleed. Option c is incorrect because subcutaneous tissue sits beneath the dermis and is mostly fat lobules that store energy, insulate, and cushion. Visible fat in a wound signals full thickness loss rather than the site of sensory receptors. Option d is incorrect because the horny cell layer is the outermost band of dead keratinised cells within the epidermis. It waterproofs the surface and sheds about every four weeks, and it contains nothing vascular.

Correct Answer: "Addiction is uncommon when opioids treat short term pain."

Naming the fear and correcting it directly addresses the barrier. Risk of addiction is low when opioids are used appropriately for acute pain, and the nurse can also separate tolerance and dependence from addiction. Option a is incorrect because agreeing with the fear leaves it in place and quietly endorses going without relief. Unrelieved surgical pain keeps this client from deep breathing and coughing, which invites atelectasis. Option b is incorrect because waiting until pain turns severe means chasing it, and severe pain takes more drug to control than steady dosing would have needed. That advice worsens the very risk the client fears. Option d is incorrect because documenting a refusal without exploring it abandons the conversation. Charting is not an intervention, and the belief driving the refusal will still be there at the next scheduled dose.

Correct Answer: Painful loose dentures and a sore mouth

All four raise risk, but pain that stops chewing blocks intake right now and forces dietary pattern changes that cost protein, vitamins and minerals. Dentures can be refitted, so the barrier is correctable. Option b is incorrect because a fading sense of smell does lower interest in food and belongs in the assessment, yet it is addressed with herbs, spices, lemon and texture contrast rather than urgent intervention. Option c is incorrect because eating alone genuinely lowers intake, and shared or congregate meals improve it measurably. Still, this client can chew, so the mechanical barrier remains the more pressing problem today. Option d is incorrect because a tight budget forces trade offs between food, medicine and heat and warrants screening for food insecurity. Careful budgeting on its own does not yet mean the client is going without.