ATI LPN
Skin Integrity Practice Questions Questions
Question 1 of 5
A nurse assesses the carbon monoxide level of a client following a burn injury and notes that the level is 8%. Based on this level, which finding would the nurse expect to note during the assessment of the client?
Correct Answer: A
Rationale: A carbon monoxide level of 8% is mild (<10%) and may cause tachycardia as the body compensates for reduced oxygen-carrying capacity.
Question 2 of 5
A client with severe psoriasis has a nursing diagnosis of Chronic Low SelfEsteem. The nurse uses which therapeutic strategy when working with this client?
Correct Answer: A
Rationale: Listening attentively fosters trust and supports self-esteem by validating the client's feelings.
Question 3 of 5
A nurse is doing a shift assessment on a group of patients after first taking report. An elderly patient is having her second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new rash on the patients chest. The nurse should ask what priority question regarding the presence of a reddened rash?
Correct Answer: B
Rationale: The nurse should suspect an allergic reaction to the antibiotic therapy. Allergies can be a significant threat to the patient's immediate health, thus questions addressing this possibility would be prioritized over those addressing sensation.
Question 4 of 5
A nurse in the emergency department (ED) is triaging a 5-year-old who has been brought to the ED by her parents for an outbreak of urticaria. What would be the most appropriate question to ask this patient and her family?
Correct Answer: A
Rationale: Foods can cause skin reactions, especially in children.
Question 5 of 5
An elderly individual from an assisted living facility presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was too hot" and that the "patient sat in the water too long." What should the nurse do?"
Correct Answer: B
Rationale: In cases of suspected abuse, especially in vulnerable patients such as children, elderly, and mentally impaired, it is important to assess the injured patient separately from the caregiver. While obtaining safety information on the temperature of the water heater is important, it is not a priority assessment question. The nurse should follow the hospital protocol for contacting appropriate authorities concerning suspected abuse, which may include contacting the police or social services. Asking the caregiver to describe how the injury occurred is important(e.g., there may be discrepancies in the physical assessment and reported mechanism of burn injury); however, examining the patient away from the caregiver is a priority.