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

Correct Answer: Zinc is depleted

Stalled wound healing paired with blunted taste, hair loss and dermatitis around the mouth is the zinc picture, and malabsorptive bariatric procedures make this trace mineral a frequent casualty. Option a is incorrect because a wound stalls with low vitamin C as well, yet scurvy adds bleeding spongy gums, corkscrew hairs and bruising. Taste change and perioral rash are not features of it. Option b is incorrect because vitamin A depletion attacks vision and the eye surface, giving night blindness, dry conjunctivae and rough follicular bumps on the arms. Flavor loss does not belong to that pattern. Option c is incorrect because thiamine loss threatens the brain and the heart, producing confusion with eye movement paralysis and staggering, or swelling from high output failure. Hair and skin remain unaffected.

Correct Answer: The client is at high risk

On the Braden Scale a lower total means higher risk, and a score in the low teens places this client in the high risk band. Immobility is the single most important risk factor. Option a is incorrect because totals in the range of nineteen to twenty-three describe a client who is not at risk. A score less than half of the maximum signals substantial vulnerability instead. Option c is incorrect because mild risk sits in the middle of the scale, around fifteen to eighteen points. Scoring several points below that band moves the client into a much more urgent category. Option d is incorrect because the six subscales give a usable total as soon as they are scored. Sensory perception, moisture, activity, mobility, nutrition, and friction with shear together yield an immediate risk category.

Correct Answer: Score the client with a dementia pain tool

When self report is no longer possible, a validated observational tool for advanced dementia captures breathing, vocalization, facial expression, body language, and consolability. Scoring during care rather than at rest reveals the pain. Option a is incorrect because silence from someone who has lost language is not a denial. Charting absence of pain on that basis is how clients with dementia end up receiving less analgesia than everyone else. Option b is incorrect because a zero to ten rating needs abstract reasoning this client has lost. A simple yes or no question about hurting may still work, but a number will not. Option c is incorrect because reaching for sedation converts a communication problem into a chemical one. Resistance during hands on care is a recognized pain behavior, and covering it leaves the underlying cause working away untouched.

Correct Answer: Supplements, allergies and religious food practices

The dietary history is not finished until the nurse asks about vitamins and herbal products, food allergies, cultural and religious practices, and whether the client can afford and store the food prescribed. Option a is incorrect because counting exact calories at the bedside belongs to a dietitian and a formal calorie count. The nursing history gathers pattern, barriers and beliefs rather than arithmetic totals for every plate. Option c is incorrect because a lipid result is a laboratory value, useful for cardiovascular risk but silent on what the client actually eats. It cannot reveal an allergy or a fasting practice. Option d is incorrect because sleep timing sits in the functional assessment, and only meal timing matters nutritionally. Knowing when the client wakes will not uncover a herbal product interacting with a prescribed drug.

Correct Answer: Pustules, cavities filled with pus

Turbid fluid means pus, and a circumscribed elevated cavity of pus is a pustule. Acne, impetigo, and folliculitis are the classic examples, and the yellow colour separates it from a vesicle. Option a is incorrect because vesicle fluid is free and clear, the serum that leaks out when a chickenpox blister is opened. Cloudy yellow contents indicate that pus has collected inside the cavity. Option b is incorrect because papules are solid throughout, with no cavity and nothing to express. A wart or an elevated naevus feels firm under the fingertip rather than soft and fluid filled. Option d is incorrect because a nodule is solid as well, larger than one centimetre, and extends deeper into the dermis. Fibromas and intradermal naevi fit that description; these chin lesions do not.

Correct Answer: The mole that changed shape and itches

Evolution matters most. Change in size, shape, colour, elevation, or symptom over time is the single most predictive feature of melanoma, and new itching or shape change outweighs any static measurement. Option b is incorrect because mild asymmetry alone is weak evidence. Asymmetry counts only as one letter of the rule, and a mole that has looked the same for years carries far less risk. Option c is incorrect because one even colour throughout is what benign naevi look like. Colour variation, especially patches of white, red, or blue, is the worrying finding, and this mole has none. Option d is incorrect because five millimetres sits under the six millimetre threshold the rule uses. Size on its own is the least specific criterion, and a stable small mole needs only routine observation.

Correct Answer: The cyst is primary, the keloid secondary

A cyst is a primary lesion, an encapsulated cavity arising in skin that was previously unaltered. A keloid is secondary, since scar tissue overgrows only after an injury has already healed. Option a is incorrect because calling the keloid primary ignores its origin. Keloids grow out of healed wounds, piercings, burns, and acne scars, extending beyond the original margins long after the skin was first broken. Option b is incorrect because the cyst does not belong in the secondary group. It develops in intact dermis or subcutaneous tissue as the first thing the skin does, which is the test for a primary lesion. Option d is incorrect because this reverses both terms. Encapsulation in previously normal skin makes the cyst primary, and excess scar tissue crossing an old wound boundary makes the keloid secondary every time.

Correct Answer: Stage three pressure injury

Visible adipose tissue marks full-thickness skin loss, which is stage three. Granulation and rolled edges support it, and because no fascia, muscle, tendon, or bone shows, the injury has not reached stage four. Option a is incorrect because partial-thickness wounds stop at the dermis, and fat is never visible in them. Granulation tissue and rolled edges also disqualify a wound from the second stage entirely. Option b is incorrect because stage four requires exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. The nurse could neither see nor touch any of those deeper structures here. Option c is incorrect because deep tissue injury presents as maroon or purple discolouration under skin that is often still closed, or as a blood-filled blister. This wound is frankly open.

Correct Answer: An overactive thyroid gland

Excess thyroid hormone raises metabolic rate and blood flow to the skin, leaving it warm, moist, and velvety smooth. This texture change is one of the classic surface clues to hyperthyroidism. Option b is incorrect because too little thyroid hormone slows metabolism and produces the opposite surface: rough, dry, coarse, flaky, and cool skin. Heat intolerance and weight loss also run counter to that picture. Option c is incorrect because reduced arterial flow leaves the lower legs shiny, thin, hairless, and cool, with thickened nails. That distribution is limited to the extremities and never produces generalized warm moist skin. Option d is incorrect because retained urochrome pigment gives a yellow green to gray tan cast with intense itching and scratch marks. Failing kidneys change color and comfort, not the silky texture described.

Correct Answer: Symmetric coolness is environmental, asymmetric coolness is vascular

Cool hands and feet in a cold room reflect the environment acting on both sides equally. A limb that is cooler than its partner points to reduced arterial flow on that side and needs pulse and perfusion checks. Option a is incorrect because ambient cold reaches both legs equally and cannot create a one sided difference. Something local to the right leg is narrowing flow, and blaming the thermostat would delay that assessment. Option c is incorrect because thyroid deficiency cools the whole body surface and brings dry coarse skin, fatigue, and cold intolerance. A single colder calf sits outside any generalized endocrine explanation. Option d is incorrect because localized coolness may be the first clue to arterial occlusion, an immobilized limb, or Raynaud phenomenon. Stopping here leaves a potentially threatened limb unexamined and unreported.