ATI LPN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
A 25-year-old woman with a minor laceration moans about arm pain after an accident with her son. Her expression of pain is possibly influenced by:
Correct Answer: D
Rationale: Pain expression varies. Worry about her son heightens anxiety, amplifying pain perception, per stress-pain links. Blood may shock but not sustain moaning. Culture influences but lacks context here. Relief reduces stress. Maternal concern drives intensity, an LPN note, making it the correct influence.
Question 2 of 5
Which item should the nurse use first to assist in staging an ulcer on a patient with darkly pigmented skin?
Correct Answer: D
Rationale: Staging ulcers in darkly pigmented skin requires accurate visualization. A halogen light is used first, per the text, to enhance inspection by countering fluorescent light's blue tones, revealing subtle redness or discoloration. Measuring tape sizes wounds later. Cotton applicators assess depth, not initial staging. Sterile gloves ensure infection control but don't aid visibility. Proper lighting is critical for the first step inspection ensuring nurses correctly identify stages like nonblanchable erythema, making this the correct initial tool.
Question 3 of 5
Which nursing observation will indicate the wound healed by secondary intention?
Correct Answer: D
Rationale: Secondary intention, for wounds like burns, leaves severe scarring (Choice D), per the text, as open wounds fill with scar tissue, potentially impairing function. Minimal tissue loss and minimal scarring suit primary intention. Dark redness isn't typical. Severe scarring reflects the healing process's extent, a key observation nurses document, making this the correct indicator of secondary intention healing.
Question 4 of 5
Which nutrient will the nurse most likely increase after collaboration with the dietitian for a patient with a Stage III pressure ulcer?
Correct Answer: B
Rationale: Protein is critical for wound healing, per the text, supporting collagen synthesis and tissue repair in Stage III ulcers. Fats and carbohydrates provide energy but aren't primary. Vitamin E isn't emphasized. Nurses and dietitians boost protein (e.g., 1.25-1.5 g/kg/day) to heal deep wounds, making this the correct nutrient to increase.
Question 5 of 5
Which next step will the nurse anticipate for a pressure ulcer that is black?
Correct Answer: C
Rationale: Black tissue is necrotic, requiring debridement (Choice C), per the text, to remove infection sources and promote healing. Monitoring delays care. Documentation follows action. Drainage isn't primary. Debridement clears the wound bed, making this the correct anticipated step.