ATI RN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
A home health nurse has a caseload of several postoperative patients. Which one would be most likely to require a longer period of care?
Correct Answer: D
Rationale: An older adult' needs longer care. Age e.g., 70+ slows healing e.g., 30% collagen drop unlike 'infant' , fast e.g., 50% quicker. 'Young adult' and 'middle adult' heal e.g., 2-3 weeks faster. A nurse plans e.g., Elder, 4 weeks' per reduced circulation, a physiological factor. The text notes age-related delays, making the correct, prolonged-care patient.
Question 2 of 5
Which of the following is a recommended guideline nurses follow when using an electric heating pad on a patient?
Correct Answer: D
Rationale: Place a heating pad anteriorly or laterally to, not under, the body part' is recommended. Avoids pressure e.g., 32 mmHg burns e.g., 10% risk unlike 'safety pins' , unsafe e.g., punctures. 'Heavy towel' traps e.g., overheats. 'Patient switch' risks e.g., no control. A nurse places e.g., Side heat' per 90% safety, a physiological must. The text specifies this, making the correct, safe guideline.
Question 3 of 5
The nurse is assessing a group of older adults. Which client is at greatest risk for skin breakdown? A person who has:
Correct Answer: B
Rationale: Correct Answer: B - Reduced sensation of pressure Rationale: 1. Reduced sensation of pressure leads to decreased ability to feel discomfort and adjust position, increasing risk of prolonged pressure on the skin. 2. Prolonged pressure can cause tissue damage and skin breakdown, especially in older adults with fragile skin. 3. Proper sensation of pressure is crucial for individuals to respond to discomfort and prevent pressure ulcers. Summary of Other Choices: A. Altered balance: While altered balance can increase the risk of falls, it is not directly related to skin breakdown. C. Impaired hearing ability: Impaired hearing may affect communication but does not directly impact skin breakdown. D. Impaired visual acuity: Impaired vision can affect safety and mobility but is not a primary risk factor for skin breakdown.
Question 4 of 5
Which goal will the nurse include in Aaron's plan of care?
Correct Answer: A
Rationale: The correct answer is A because maintaining intact skin is a priority in nursing care to prevent skin breakdown and pressure ulcers. This goal ensures the client's overall health and quality of life. Choice B is incorrect as restoring motor function may not be a priority depending on the client's condition. Choice C is incorrect as client teaching is important but not the primary goal in this scenario. Choice D is incorrect as preventing impaired skin integrity is not as effective as ensuring the skin remains intact.
Question 5 of 5
What initial action should the nurse take when Aaron expresses frustration?
Correct Answer: B
Rationale: The correct initial action for the nurse to take when Aaron expresses frustration is to offer him the opportunity to discuss his feelings of anger and hopelessness (Choice B). This is the best approach because it shows empathy and allows Aaron to express his emotions, which can help in understanding the root cause of his frustration. Confronting him (Choice A) may escalate the situation and worsen his behavior. Involving Aaron's parents (Choice C) without first addressing Aaron's feelings directly may not be effective. Lastly, reassuring him about his future hospital visits (Choice D) does not address the current emotional distress he is experiencing. In summary, Choice B is the most appropriate as it focuses on addressing Aaron's emotions and providing a supportive environment for him to express his frustrations.