ATI RN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
A 5-year-old girl has been presented for care by her father due to her recent development of macules on her trunk, extremities, and mucous membranes. The child is mildly febrile, but her primary symptom is extreme pruritus. What disorder of the skin should the clinician who is assessing the child first suspect?
Correct Answer: A
Rationale: The correct answer is A: Varicella. The presentation of macules on the trunk, extremities, and mucous membranes along with extreme pruritus and mild fever is classic for varicella (chickenpox). Varicella is a common childhood viral infection caused by the varicella-zoster virus. The initial macules progress to vesicles and then crust over. The child's age, distribution of skin lesions, and symptoms all point towards varicella. Lichen planus (B) typically presents as purple, itchy, flat-topped papules. Rosacea (C) is a chronic skin condition characterized by facial redness and acne-like bumps. Impetigo (D) is a bacterial skin infection that typically presents with honey-colored crusts and blisters.
Question 2 of 5
Which is the first intervention of the nurse for changing the dressing to a painful burn?
Correct Answer: A
Rationale: For a painful burn dressing change, 'administer pain medication 30 minutes beforehand' is first, per Potter's *Essentials*. Analgesia e.g., morphine 5 mg peaks in 30 minutes, cutting pain (e.g., 8/10 to 3/10), unlike 'irrigate' , second e.g., after comfort. 'Loosen tape' follows e.g., reduces pull, not pain itself. 'Observe' assesses e.g., later step. A nurse plans e.g., Meds at 0900, change at 0930' ensuring comfort (e.g., 80% report less distress), a basic care priority. Potter stresses preemptive pain control, making the correct, initial intervention.
Question 3 of 5
Which assessment charting indicates that the wound is healing by primary intention?
Correct Answer: A
Rationale: The 4-inch incision edges are well approximated with intact sutures' shows primary intention, per Potter's *Essentials*. Clean closure e.g., sutured within 6 hours heals fast e.g., 7 days unlike 'ulcer with slough' , secondary e.g., open, slow. 'Deep incision with granulation' is secondary e.g., fills in. 'Abrasion' is superficial e.g., not sutured. A nurse charts e.g., Edges tight' primary's 80% rate, per surgical norms, a physiological marker. Potter contrasts with secondary's gap, making the correct, primary sign.
Question 4 of 5
The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient?
Correct Answer: B
Rationale: A Stage IV ulcer requires 'full-thickness wound repair'. Deep loss e.g., bone exposed heals via scar e.g., 4 phases: hemostasis to maturation unlike 'partial-thickness' , epidermal e.g., Stage II. 'Primary intention' is surgical e.g., closed fast. 'Tertiary intention' delays closure e.g., not typical. A nurse plans e.g., Debride, pack' per 20% Stage IV rate, a physiological focus. The text ties Stage IV to full repair, making the correct, deep healing type.
Question 5 of 5
A nurse is caring for a patient with a wound. Which assessment data will be most important for the nurse to gather with regard to wound healing?
Correct Answer: B
Rationale: Pulse oximetry assessment' is most critical for wound healing. Oxygen saturation e.g., 95% fuels repair e.g., collagen needs 20 mmHg unlike 'muscular strength' , mobility e.g., not direct. 'Sensation' checks nerves e.g., not oxygen. 'Sleep' aids rest e.g., indirect. A nurse measures e.g., SpO2 88%' per 30% healing delay risk, needing O2 therapy. The text ties perfusion to healing, a physiological priority, making the correct, vital data.