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

Correct Answer: Palpate both legs for warmth, induration and tautness

Inflammation in dark skin reads as a purplish or darker tinge that is easily missed, so touch supplies the reliable data. Warmth, induration, tautness and edema compared against the unaffected leg confirm the process. Option a is incorrect because a printed chart cannot represent the range of normal pigmentation. The comparison that matters is with an unaffected area on this same client, which is the only meaningful baseline. Option b is incorrect because fluorescent lighting distorts color perception, and natural or full spectrum light is preferred. Better light still leaves the nurse relying on a color change that pigment largely conceals. Option d is incorrect because blanching tests capillary refill and the character of a rash rather than the presence of inflammation. In heavily pigmented skin the color return cannot be seen well enough to interpret.

Correct Answer: Some contractions are too weak to reach the wrist

An apical radial deficit means some ventricular contractions eject too little blood to produce a palpable peripheral pulse. Atrial fibrillation and premature ventricular contractions do this, and any deficit must be reported. Option a is incorrect because the two nurse method exists precisely to capture this difference. Counting at the same moment on the same watch removes the timing error that a repeat count would be looking for. Option c is incorrect because a blocked radial artery would weaken that one wrist while the other side stayed strong. A deficit arising from local plaque does not explain a whole minute of missing beats. Option d is incorrect because powerful ejection sends every beat all the way to the periphery, producing matched rates rather than a gap. A strong stroke volume would raise amplitude, not create missing peripheral beats.

Correct Answer: The behavior may be a sign of respect

Reduced eye contact is normative in many groups and often signals deference rather than depression or evasion. The corrective question is whether the behavior is usual within this client's own community. Option a is incorrect because depression is diagnosed from mood, sleep, appetite, interest and thought content, not from where a client rests her gaze. Labeling a cultural norm as pathology is the classic error. Option b is incorrect because averted gaze is read as deceit only inside cultures that expect steady eye contact. Assuming concealment damages trust and invites the nurse to discount whatever the client does report. Option d is incorrect because hearing loss shows itself in misheard questions, leaning toward the speaker, or asking for repetition. This client is answering the questions, so sensory impairment does not explain the gaze.

Correct Answer: Document the size and location of the patches

Congenital dermal melanocytosis is a normal variant in infants with darker skin, and it is repeatedly mistaken for bruising. Recording size and location on admission protects the family from a false abuse allegation. Option a is incorrect because these flat blue gray patches are present from birth and carry none of the features of inflicted injury. Reporting them as bruises would distress the family and misdirect the investigation. Option c is incorrect because cold therapy treats acute soft tissue swelling from trauma. The patches involve pigment deposited deep in the dermis, so chilling the skin changes nothing and only upsets the infant. Option d is incorrect because serial measurement is used to track a resolving bruise through its color stages. This variant fades slowly over childhood rather than in days, and daily checks add nothing useful.

Correct Answer: Uncross the legs and repeat the measurement

Crossing the legs at the knee raises systolic pressure by roughly five to fifteen points, so the nurse corrects the position, lets the client settle, and takes the reading again before charting anything. Option a is incorrect because charting a value obtained with a known positioning fault passes a false number to the whole team. The provider may then treat a rise that the posture alone created. Option b is incorrect because the size of the error varies from client to client and cannot be arithmetically removed. Published ranges describe groups, not the individual sitting in front of the nurse. Option c is incorrect because switching arms addresses a suspected difference between limbs, which is a separate question. Leg position affects both arms equally, so the second arm would carry the same distortion.

Correct Answer: The oxygen saturation of 88 percent

Saturation below 90 percent sits on the steep part of the oxyhemoglobin curve, where small further drops cost a great deal. Paired with retractions, it makes breathing the first priority. Option b is incorrect because a rate slightly above 100 beats per minute is a common postoperative response to pain, fever, and hypoxemia. Treating the cause of the low saturation will usually settle it. Option c is incorrect because a small temperature rise in the first postoperative days is expected and rarely urgent. It deserves monitoring, yet it poses no threat to airway or breathing at this moment. Option d is incorrect because tachypnea alone falls short of the threshold that triggers escalation on its own. The rate matters here as evidence of the work being spent to defend a saturation that is already failing.

Correct Answer: Air is trapped within the lung tissue

Hyperresonance is normal only in children and very thin adults. In an adult with this history the booming, overly loud note signals increased air within the lungs, as in emphysema or a pneumothorax. Option a is incorrect because the expected note over healthy adult lung is resonance, which is quieter and shorter than what was heard. Students often accept a booming note as normal, and that assumption misses disease. Option c is incorrect because fluid layering in the pleural space absorbs vibration and produces dullness or even flatness. That is the opposite acoustic direction from the loud sustained note described here. Option d is incorrect because striking over bone dampens vibration and yields a short, dull or flat sound. A technique error of that kind would quiet the note rather than make it boom.

Correct Answer: Arrange a female examiner and honor her request

Modesty and gender preference are asked about and accommodated where possible. Providing a same gender examiner and letting the client choose who stays respects her values and keeps her willing to be examined. Option b is incorrect because framing her request as an obstacle pressures her to abandon a religious practice. That is cultural imposition, and clients who feel pushed frequently decline the examination altogether. Option c is incorrect because careful draping is standard practice for every client and does not answer either question she asked. Going ahead without a reply treats her stated preference as unimportant. Option d is incorrect because the client asked the questions and holds the right to consent. Handing the decision to her husband without being asked to do so removes her voice and assumes a family structure.

Correct Answer: Detecting surface tenderness, tone, and guarding

Light palpation presses roughly one centimeter and surveys the surface. It reveals skin texture, moisture, muscle tone, superficial masses and early guarding, and it accustoms the client to touch before deeper pressure is applied. Option a is incorrect because organ borders sit well below the surface and require roughly four to five centimeters of steady pressure with the palmar surface of the extended fingers. Option b is incorrect because a shallow sweep never reaches structures lying that far posteriorly. Deep palpation, applied slowly and steadily so the wall relaxes, is the technique that reaches them. Option d is incorrect because capturing an organ between an anterior and a posterior hand describes bimanual technique. One hand pressing gently in a circle cannot trap anything between two surfaces.

Correct Answer: Palpation may have produced the sounds recorded

Pressing on the abdominal wall increases peristalsis, so sounds heard afterward may be sounds the nurse generated. A hypoactive abdomen can be made to sound active, which makes the entry unreliable as baseline data. Option a is incorrect because tapping the wall stimulates the gut exactly as pressing does. Counting after percussion would carry the same distortion, which is why listening is placed second in this region. Option b is incorrect because volume is not the problem here. The stethoscope still transmits the sounds clearly, yet what it transmits has been altered by the pressure applied moments earlier. Option c is incorrect because the liver span is mapped by percussion at the right midclavicular line, with palpation confirming the edge. That detail does not address the sequence error in this chart entry.