ATI RN
NCLEX Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
A client with a previously healed tuberculosis lesion experiences lesion rupture that leads to active disease. Which type of tuberculosis does this client have?
Correct Answer: C
Rationale: Rationale: 1. The client had a previously healed lesion, indicating latent infection. 2. Rupture led to active disease, suggesting reactivation of latent infection. 3. Therefore, the client has reactivation tuberculosis. Summary: - A: Miliary TB is widespread dissemination, not related to a single lesion. - B: Extrapulmonary TB affects organs other than the lungs. - D: Cavitation TB involves formation of cavities in the lungs, not directly related to lesion rupture.
Question 2 of 5
Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma (BCC)?
Correct Answer: C
Rationale: The correct answer is C because minimizing sun exposure is crucial in preventing future basal cell carcinoma (BCC) development. Sun exposure is a major risk factor for BCC, so educating the patient on sun protection measures is essential. Choice A is incorrect as watchful waiting is not a typical treatment plan for BCC. Choice B is incorrect because BCC rarely metastasizes. Choice D is incorrect because systemic chemotherapy is not a common treatment for BCC. Overall, educating the patient on sun protection is key in managing and preventing BCC.
Question 3 of 5
A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure?
Correct Answer: D
Rationale: The correct answer is D: Surgical excision. This is the most appropriate procedure for removing a suspicious mole that is irregular, enlarging, and potentially malignant. Surgical excision allows for the complete removal of the mole along with a margin of healthy tissue to ensure that all abnormal cells are eliminated. Curettage (A) involves scraping the skin surface and may not be sufficient for complete removal. Cryosurgery (B) freezes and destroys tissue but may not be adequate for excising a potentially malignant lesion. Punch biopsy (C) is used for sampling a small portion of the mole for diagnostic purposes, not for complete removal.
Question 4 of 5
The nurse assesses a patient who has just arrived in the post-anesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately?
Correct Answer: C
Rationale: The correct answer is C because the inability to detect when the eyelids are touched may indicate nerve damage, which is a critical post-operative complication following a blepharoplasty. This should be reported immediately to the surgeon for prompt evaluation and intervention to prevent further complications. Choice A is incorrect because incisional pain is expected after surgery and can be managed with pain relief medications. Choice B, a heart rate of 110 beats/min, is elevated but not an immediate concern unless other symptoms are present. Choice D, pale and cold skin around the incision, may indicate poor circulation but is not as urgent as nerve damage in this context.
Question 5 of 5
Which medication information will the nurse identify as a potential risk to a patient’s musculoskeletal system?
Correct Answer: C
Rationale: The correct answer is C because oral corticosteroids, used to treat severe asthma, can lead to musculoskeletal issues like osteoporosis and muscle weakness. Corticosteroids can decrease bone density and increase the risk of fractures. A: Taking multivitamins and calcium supplements promotes bone health. B: Hormone replacement therapy does not directly impact the musculoskeletal system. D: NSAIDs are not typically associated with musculoskeletal risks unless used in high doses for prolonged periods.