ATI LPN
Skin Integrity Practice Questions Questions
Question 1 of 5
A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development?
Correct Answer: C
Rationale: Being immobile and incontinent are two significant risk factors for the development of pressure ulcers, making the 65-year-old at highest risk.
Question 2 of 5
A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take?
Correct Answer: B
Rationale: Symptoms suggest carbon monoxide poisoning, requiring a carboxyhemoglobin level check.
Question 3 of 5
A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from the upper back. The nurse should prepare the patient for which type of biopsy?
Correct Answer: C
Rationale: An incisional biopsy would remove the entire mole and the tissue borders. The appearance of the mole indicates that it may be malignant. A shave biopsy would not remove the entire mole. The mole is too large to be removed with punch biopsy. Excisional biopsies are done for smaller lesions and where a good cosmetic effect is desired, such as on the face.
Question 4 of 5
When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin; thin hair; and thick, brittle nails. What is the nurse's best action?
Correct Answer: C
Rationale: The patient has clinical manifestations that could be caused by systemic problems such as malnutrition or hypothyroidism, so further diagnostic evaluation is indicated. Patient teaching about nutrition, addressing the patient's dry skin, and referral to a podiatrist may also be needed, but the priority is to rule out underlying disease that may be causing these manifestations.
Question 5 of 5
The nurse in a long-term care facility is teaching a group of new unlicensed assistive personnel. Which information regarding skin care should the nurse emphasize?
Correct Answer: C
Rationale: Turning immobile clients every 2 hours prevents pressure ulcers by relieving pressure on vulnerable areas.