ATI LPN
Skin Integrity Nursing Questions Questions
Question 1 of 5
A client is brought to the emergency room following a burn injury. In assessment the nurse notes that the client's eyebrow and nasal hairs are singed. The nurse would identify this type of burn as:
Correct Answer: A
Rationale: Singed eyebrow and nasal hairs indicate exposure to heat and flames, characteristic of a thermal burn, often with inhalation injury risk.
Question 2 of 5
A student nurse is instructed by the registered nurse to monitor a client who has dark skin for cyanosis. The registered nurse determines that the student needs instructions regarding physical assessment techniques for the dark-skinned client if the student states that the best area to assess for cyanosis was in the:
Correct Answer: C
Rationale: In dark-skinned clients, cyanosis is best assessed in the sclera, conjunctiva, or oral mucosa, not nail beds or lips, due to pigmentation.
Question 3 of 5
An African American is admitted to the medical unit with liver disease. To correctly assess this patient for jaundice, on what body area should the nurse look for yellow discoloration?
Correct Answer: D
Rationale: Jaundice, a yellowing of the skin, is directly related to elevations in serum bilirubin and is often first observed in the sclerae and mucous membranes.
Question 4 of 5
A nurse is conducting a health interview and is assessing for integumentary conditions that are known to have a genetic component. What assessment question is most appropriate?
Correct Answer: A
Rationale: Eczema and psoriasis are known to have a genetic component.
Question 5 of 5
A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for:
Correct Answer: C
Rationale: Intraabdominal hypertension(IAH) is a serious complication caused by circumferential torso burn injuries or edema from aggressive fluid resuscitation. Signs and symptoms of IAH include tense abdomen, decreased urine output, and worsening pulmonary function. Acute kidney injury will not result from aggressive fluid resuscitation. Acute respiratory distress syndrome would present with signs of hypoxia and hypercarbia, but not a tense abdomen. Disseminated intravascular disorder may present as a tense abdomen if there is active bleeding, but it would not present with pulmonary symptoms.