D443 Health Assessment - Set 3 - Part 2

Correct Answer: Vesicle

A vesicle is a small, elevated, circumscribed, fluid-filled lesion measuring less than 0.5 centimeters in diameter, such as those seen in herpes simplex or early varicella. A bulla is essentially a larger version of the same, a fluid-filled lesion greater than 0.5 centimeters, as seen in a large blister or a second-degree burn. A pustule is a raised lesion filled with purulent fluid, as in acne or impetigo, and a wheal is a transient, raised, irregular area of edema, such as a hive. Accurate identification of primary lesions by size and content guides correct documentation and diagnosis.

Correct Answer: Asymmetry

In the ABCDE melanoma screening rule, asymmetry refers to a lesion in which one half does not match the other half when an imaginary line is drawn through the middle. Benign moles are typically symmetric, while asymmetry raises suspicion for malignancy. The remaining criteria are border (irregular, ragged, or poorly defined edges), color (variation or multiple shades within the lesion), diameter (greater than 6 millimeters, about the size of a pencil eraser), and evolving (any change in size, shape, color, or symptoms over time). Recognizing asymmetry helps the nurse identify moles that warrant further evaluation.

Correct Answer: Unstageable pressure injury

An unstageable pressure injury is a full-thickness wound in which the base is obscured by slough or eschar, making it impossible to determine the true depth and therefore the stage. Until enough of the nonviable tissue is removed to expose the wound base, the injury cannot be accurately classified as stage 3 or stage 4. A deep tissue pressure injury, by contrast, presents as intact or nonintact skin with a persistent, nonblanchable deep red, maroon, or purple discoloration. Recognizing an unstageable injury directs the nurse toward appropriate debridement and reassessment once the base becomes visible.

Correct Answer: It predicts pressure injury risk, with lower total scores indicating higher risk

The Braden Scale is a validated risk-assessment tool that predicts a patient's risk for developing pressure injuries by scoring six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. A lower total score indicates greater risk, allowing nurses to implement preventive interventions before breakdown occurs. It does not stage existing wounds, measure hydration, or classify lesion types. Using the Braden Scale on admission and at regular intervals enables early identification of at-risk patients and guides the intensity of preventive care such as repositioning and support surfaces.

Correct Answer: It systematically screens each body system for symptoms the patient may not have mentioned

The review of systems is a systematic, head-to-toe inventory of subjective symptoms in which the nurse asks about each body system to uncover problems the patient may not have volunteered or connected to the present illness. It consists of the patient's report of the presence or absence of symptoms and does not include physical examination findings, which are objective data. It is separate from the chief complaint, which captures the primary reason for the visit, and from the medication and allergy history. The review of systems helps ensure that no significant symptom is overlooked during the comprehensive assessment.

Correct Answer: Cheyne-Stokes respirations

Cheyne-Stokes respirations are characterized by a cyclic pattern of gradually increasing then gradually decreasing depth of breathing, followed by a period of apnea before the cycle repeats. This pattern is associated with heart failure, cerebral injury, and the dying process. Kussmaul respirations are deep, rapid, and labored breaths seen in metabolic acidosis such as diabetic ketoacidosis. Biot respirations are irregular breaths of variable depth alternating with periods of apnea without the crescendo-decrescendo pattern. Eupnea refers to normal, even, unlabored breathing. Correctly identifying the pattern guides the nurse toward the underlying cause.

Correct Answer: It persists beyond the expected period of healing, often lasting longer than three to six months

Chronic pain persists beyond the expected time frame for tissue healing, typically defined as lasting longer than three to six months, and may continue after the original injury has resolved or without an identifiable cause. Unlike acute pain, which has a recent, sudden onset and warns of tissue damage, chronic pain often lacks the sympathetic nervous system responses such as elevated heart rate and blood pressure because the body adapts over time. Chronic pain can significantly affect mood, function, and quality of life. Distinguishing the two guides appropriate assessment and management strategies for each type.

Correct Answer: 37.0 degrees Celsius (98.6 degrees Fahrenheit)

The normal average adult oral temperature is approximately 37.0 degrees Celsius (98.6 degrees Fahrenheit), with a normal range generally accepted as about 36.5 to 37.5 degrees Celsius. A temperature of 35.0 degrees Celsius represents hypothermia, while temperatures of 38.5 and 39.4 degrees Celsius represent pyrexia, or fever. Body temperature varies with the route of measurement, time of day, activity, and hormonal fluctuations. Knowing the normal range allows the nurse to accurately recognize hypothermia and fever, both of which may indicate underlying physiological problems requiring intervention.

Correct Answer: Nodding and saying 'go on' or 'tell me more' to encourage the patient to elaborate

Facilitation is a therapeutic communication technique in which the nurse uses verbal cues such as 'go on' or 'tell me more' and nonverbal cues such as nodding and maintaining eye contact to encourage the patient to continue sharing information without interruption. It shows the patient the nurse is listening and interested, promoting a fuller narrative. Offering false reassurance can shut down communication and dismiss the patient's concerns, using jargon can confuse the patient, and rapid closed-ended questions limit the depth of the patient's response. Facilitation keeps the patient talking and builds rapport during the interview.

Correct Answer: The oral mucous membranes, conjunctivae, lips, and nail beds

Cyanosis, a bluish discoloration caused by increased deoxygenated hemoglobin, is most reliably detected in areas with abundant blood vessels and thin, minimally pigmented tissue, such as the oral mucous membranes, conjunctivae, lips, and nail beds. These sites reveal color changes that may be masked in the outer skin, particularly in patients with darker skin tones where surface color changes are harder to appreciate. Inspecting these highly vascular mucosal and nail bed areas gives the nurse a more accurate assessment of oxygenation, allowing earlier recognition of hypoxia than relying on the general skin surface alone.

Correct Answer: Giant cell (temporal) arteritis

Giant cell (temporal) arteritis is a vasculitis of medium and large arteries, classically the temporal artery, seen in adults over fifty. The hallmark cluster of unilateral temporal headache, scalp tenderness, and jaw claudication (jaw pain with chewing) strongly suggests it, and transient monocular vision changes signal impending ischemic optic neuropathy. Because untreated arteritis can cause sudden, irreversible blindness, it is a medical emergency requiring prompt corticosteroids and an elevated erythrocyte sedimentation rate confirms the inflammatory process. Migraine, tension headache, and trigeminal neuralgia do not produce jaw claudication or threaten vision in this manner.

Correct Answer: Retinoblastoma or congenital cataract

The red reflex is produced when light passes through a clear lens and vitreous and reflects off the vascular retina, appearing as a symmetric red-orange glow. A white reflex (leukocoria) means light is being blocked or reflected by an abnormal structure, most concerning for retinoblastoma, a malignant intraocular tumor, or a congenital cataract clouding the lens. Both require urgent ophthalmology referral because early treatment of retinoblastoma is sight- and life-saving. A normal red reflex should be present regardless of skin pigmentation, and jaundice or a subconjunctival hemorrhage would not obscure the red reflex.

Correct Answer: Peripheral visual fields

This is the confrontation test, a gross screening of peripheral visual fields in which the examiner compares the patient's field of vision to their own presumably normal field. As a target is brought in from the periphery in each quadrant, the patient reports when it appears, revealing field deficits such as those from glaucoma, retinal disease, or stroke. Central acuity is measured with a Snellen chart, extraocular alignment with the six cardinal positions of gaze, and accommodation by observing convergence and pupil constriction as a target nears the nose. The confrontation test specifically maps the outer boundaries of what the patient can see.

Correct Answer: Cranial nerves II and III

The direct light reflex depends on an intact afferent and efferent pathway. Cranial nerve II (optic) carries the sensory signal of light from the retina to the brain, and cranial nerve III (oculomotor) carries the motor signal that causes the pupillary sphincter to contract and constrict the pupil. If either nerve is damaged, the direct light reflex is impaired. Cranial nerves IV and VI control extraocular movement, cranial nerve V provides facial sensation, cranial nerve VII controls facial expression, and cranial nerve I mediates smell, none of which drive the pupillary light response.

Correct Answer: Arcus senilis, a benign age-related change

Arcus senilis is a grayish-white ring of lipid deposits at the periphery of the cornea that commonly develops with aging and is considered a normal, benign finding in older adults that does not affect vision. It requires no treatment when it appears in elderly patients. A corneal infection would present with redness, pain, and discharge; a cataract clouds the lens itself, producing blurred vision; and a pterygium is a wedge-shaped growth of conjunctival tissue extending onto the cornea. The circumferential lipid ring with no visual change is characteristic of arcus senilis.

Correct Answer: Age-related macular degeneration

Age-related macular degeneration damages the macula, the central portion of the retina responsible for sharp central vision, producing a central scotoma with preserved peripheral vision. Patients report difficulty recognizing faces, reading, and seeing distorted or wavy straight lines, which is why the Amsler grid is used to monitor it. Open-angle glaucoma characteristically erodes peripheral vision first while sparing central vision, and acute angle-closure glaucoma causes sudden painful vision loss with a red eye and halos. Retinal detachment typically causes floaters, flashes, and a curtain-like field loss rather than a central distortion.

Correct Answer: Elevated intraocular pressure with gradual peripheral vision loss and increased optic cup-to-disc ratio

Chronic open-angle glaucoma results from impaired drainage of aqueous humor, which raises intraocular pressure and slowly damages the optic nerve. The classic ophthalmoscopic finding is an enlarged optic cup, seen as an increased cup-to-disc ratio, and the vision loss begins peripherally and progresses gradually, often unnoticed until advanced. Lens clouding with glare and halos describes cataracts, conjunctival inflammation with discharge describes conjunctivitis, and sudden central vision loss is not the typical presentation of chronic glaucoma. Elevated pressure with peripheral field loss and optic disc cupping is the defining triad.

Correct Answer: Arteriovenous nicking where arterioles cross veins

Chronic hypertension thickens and stiffens retinal arteriole walls, and where a rigid arteriole crosses a vein it compresses the underlying vessel, producing arteriovenous nicking, a hallmark of hypertensive retinopathy. Other findings include copper- or silver-wire arterioles, flame-shaped hemorrhages, and cotton-wool spots. An absent red reflex suggests lens or vitreous opacity, a cupped optic disc suggests glaucoma, and yellow macular deposits (drusen) suggest macular degeneration. Arteriovenous nicking specifically reflects the vascular remodeling caused by sustained high blood pressure.

Correct Answer: Subconjunctival hemorrhage, a benign and self-limiting condition

A subconjunctival hemorrhage is bleeding from a small blood vessel underneath the conjunctiva, producing a striking, well-demarcated red patch over the sclera. It is typically painless, does not affect vision or produce discharge, and often follows a sudden rise in venous pressure from coughing, straining, or sneezing. It resolves on its own over one to two weeks without treatment. Bacterial conjunctivitis produces diffuse redness with purulent discharge, angle-closure glaucoma causes severe pain and vision loss, and a corneal abrasion causes pain and a foreign-body sensation, none of which match this painless, isolated bleed.

Correct Answer: Acute otitis media

Acute otitis media is a middle ear infection in which fluid and pus accumulate behind the tympanic membrane, causing it to appear red, bulge outward, and lose its normal translucency, cone of light, and visible bony landmarks. This presentation with fever and otalgia in a young child is classic. Cerumen impaction obscures the canal with wax rather than reddening a bulging membrane, otitis externa causes canal swelling and pain on tragus manipulation, and while crying can redden the membrane it would not cause bulging with fluid behind it. The bulging, opaque, erythematous drum points to middle ear infection.