ATI LPN
Fundamentals Wound Care and Skin Integrity Questions Questions
Question 1 of 5
A 75-year-old client seeks care at an ambulatory clinic. The client reports having experienced extreme drowsiness after recently taking dosages of an over-the-counter cold medication. When collecting data, the nurse notes the client reports taking only the prescribed amount of the preparation. What inferences can be made by the nurse concerning the events?
Correct Answer: C
Rationale: Older clients often experience altered responses to medications due to age-related changes in the kidneys and liver. There is no evidence the client has taken too much medication or is taking other medications. Allergic reactions typically manifest with integumentary- or respiratory-related symptoms.
Question 2 of 5
A client with severe symptoms of tinnitus, vertigo, sensorineural hearing deficit, nausea, and vomiting would have which nursing diagnosis as a first priority?
Correct Answer: B
Rationale: Symptoms of Meniere's disease indicate a high risk for falls due to imbalance, making 'Trauma, Risk for' the top priority for safety.
Question 3 of 5
A client recently diagnosed with herpes simplex II asks how to best manage the lesions. What information should be given to the client?
Correct Answer: D
Rationale: Lesions should be kept clean and dry with gentle soap and water. Alcohol burns, and nylon retains moisture, worsening discomfort.
Question 4 of 5
Which finding requires immediate referral when a nurse assesses an older adult's skin?
Correct Answer: B
Rationale: The lesion with various colors fits one of the American Cancer Society hallmark signs for cancer according to the ABCD method (color variation). This requires immediate referral.
Question 5 of 5
A nurse assesses a wife who is caring for her husband with a Braden Scale score of 9. Which question should the nurse include in this assessment?
Correct Answer: B
Rationale: A Braden Scale score of 9 indicates high risk for skin breakdown; assessing the caregiver's coping is crucial.