During a skin assessment, which finding should the nurse report immediately?

Non-blanching purple area over the sacrum

Small healed scar on the arm

Freckles on the shoulders

Dry skin on the lower legs

Answer and Explanation

The Correct Answer is A

Rationale:
A. This is a critical finding that indicates possible pressure injury (pressure ulcer) or tissue ischemia. Non-blanching means that when pressure is applied, the area does not turn white, which is a hallmark sign of compromised perfusion and potential skin breakdown. Immediate reporting is necessary to prevent further tissue damage and initiate interventions such as pressure relief, wound care, and close monitoring.

B. This is an old, healed injury and is considered normal in the context of a skin assessment. It does not indicate current skin compromise and does not require urgent reporting.

C. Freckles are benign pigmented skin lesions. They are normal variations in skin pigmentation and do not indicate acute pathology or require immediate reporting.

D. While dry skin should be addressed to prevent discomfort or cracking, it is not an urgent finding. It can be managed with routine skin care and moisturizer, and does not require immediate intervention.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. Asking the patient to follow your finger through the six cardinal fields of gaze assesses extraocular muscle function and eye movement, not the "A" in PERRLA. This test evaluates cranial nerves III, IV, and VI, but it does not measure accommodation.

B. Moving your finger slowly toward the patient's nose and observing the pupils constrict and the eyes converge tests Accommodation, which is what the "A" in PERRLA represents. Accommodation involves the pupils adjusting for near vision (constricting) and convergence of the eyes, ensuring that the eyes can focus properly on close objects. This is the correct method for testing "A."

C. Shining a penlight into each eye and observing constriction of both pupils tests Pupillary Light Reflex, which corresponds to the "P" and "R" (Pupils Equal, Round, Reactive to Light) in PERRLA. This does not assess accommodation.

D. Asking the patient to focus on a distant object and then read a near vision card evaluates near and distance vision acuity, but it does not specifically test the pupillary constriction and convergence associated with accommodation.

A. Client reports nipple discharge for the past week B. Axillary lymph node enlargement observed C. Skin dimpling noted near the nipple D. Client reports breast tenderness before menstruation E. A 2-cm firm mass palpated in the right breast

Correct Answer is ["A","D"]

Explanation

Rationale:

A. Client reports nipple discharge for the past week is subjective because the nurse is relying on the client’s personal report of experiencing discharge. The nurse cannot verify this symptom without direct observation at the time of the assessment, and the timing and description come from the client’s own account.

B. Axillary lymph node enlargement observed is objective data. The nurse can directly observe or palpate the lymph nodes, measure size, and document enlargement. It is a tangible sign that does not rely on the client’s perception.

C. Skin dimpling noted near the nipple is also objective data. The nurse observes the abnormal contour or indentation of the breast skin during examination, which can be verified visually and documented.

D. Client reports breast tenderness before menstruation is subjective because it is based on the client’s personal experience of discomfort or pain, which the nurse cannot measure. Pain and tenderness are classic examples of subjective findings because they rely on the client’s report.

E. A 2-cm firm mass palpated in the right breast is objective data. The nurse can physically feel, measure, and document the mass. This finding is tangible and reproducible on examination.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

During a skin assessment, which finding should the nurse report immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing an eye assessment using the PERRLA acronym, how do test for "A"?

Correct Answer is B

Explanation

A nurse is obtaining a breast health history. Which findings represent subjective data? (Select all that apply.)

Correct Answer is ["A","D"]

Explanation

Which of the following is the correct procedure for measuring a patient's blood pressure using a manual sphygmomanometer?

A nurse is conducting a health assessment on a newly admitted patient. The patient appears anxious and begins to speak in a rushed and disorganized manner. Which of the following responses by the nurse demonstrates therapeutic communication?

A nurse is assessing a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?

A nurse is caring for a client who has an oxygen saturation of 88%. Which of the following actions should the nurse take?

After completing an initial assessment of a patient, the nurse has documented that the respirations are 16 and his pulse is 68 beats per minute. What type of assessment data is this?

A nurse is assessing a client who is receiving opioid pain medication. Which respiratory rate finding requires the nurse's immediate intervention?

A nurse is assessing an infant during a routine health examination. The nurse notes that the infant's anterior fontanel is sunken. How should the nurse interpret this finding?

A nurse is caring for a client who has a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of which of the following visual impairments?