NCLEX-PN
Integumentary System NCLEX Questions Quizlet Questions
Question 1 of 5
Which subjective symptom is the client most likely to report to the nurse?
Correct Answer: C
Rationale: Vertigo is a hallmark symptom of Meniere's disease due to inner ear fluid imbalance.
Question 2 of 5
A severely burned man had his last tetanus shot when he started work at his job two years ago. What should the nurse expect to administer now?
Correct Answer: A
Rationale: A tetanus toxoid booster is appropriate for a burn client with a tetanus shot within the past five years to ensure immunity against tetanus, common in burn wounds.
Question 3 of 5
Which client would most likely be at risk for the development of a carbuncle?
Correct Answer: D
Rationale: Diabetes increases infection risk, including carbuncles, due to impaired immunity. Shaving, fair skin, and exercise are less significant.
Question 4 of 5
The nurse assesses that the client with partial-thickness burns over 50% of the total body surface area (TBSA) has gained weight and has generalized edema after the first 24 hours. The nurse should consider that the edema and weight gain are most likely related to which physiological processes?
Correct Answer: D
Rationale: Initially after a severe burn injury there is a loss of capillary integrity and a shift of fluid, sodium, and protein from the intravascular to the interstitial spaces. The body compensates for this interstitial hemoconcentration by retaining more fluid. Sodium is lost due to diuresis, and existing sodium tends to be diluted by an influx of fluid, so serum sodium levels will be decreased, not increased. Hgb and Hct levels may change in severe burns, but they are the result of the fluid shift, not the cause. Fluid volume deficit (not excess) is a major risk during this phase.
Question 5 of 5
After cataract surgery, the client tells the nurse of severe pain in the operative eye. Which nursing action is most appropriate?
Correct Answer: A
Rationale: Severe pain may indicate complications, requiring immediate reporting to the charge nurse.