ATI LPN
Fundamentals of Nursing Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
A nurse is aware that the outer layer of the skin consists of dead cells that contain large amounts of keratin. The physiologic functions of keratin include which of the following?
Correct Answer: C
Rationale: The dead cells of the epidermis contain large amounts of keratin, an insoluble, fibrous protein that forms the outer barrier of the skin. Keratin has the capacity to repel pathogens and prevent excessive fluid loss from the body. It does not contribute directly to antibody production or electrolyte absorption.
Question 2 of 5
The nurse is caring for a patient who has circumferential full-thickness burns of his forearm? A priority in the plan of care is:
Correct Answer: B
Rationale: Special attention is given to circumferential(completely surrounding a body part) full thickness burns of the extremities. Pressure from bands of eschar or from edema that develops as resuscitation proceeds may impair blood flow to underlying and distal tissue. Therefore, extremities are elevated to reduce edema. Active or passive range-of-motion(ROM) exercises are performed every hour for 5 minutes to increase venous return and to minimize edema. Peripheral pulses are assessed every hour, especially in circumferential burns of the extremities, to confirm adequate circulation. If signs and symptoms of compartment syndrome are present on serial examination, preparation is made for an escharotomy to relieve pressure and to restore circulation.
Question 3 of 5
The nurse notes a thickening and hardening of the skin from continued irritation on an individual who is wheelchair-bound. What term should the nurse use to describe this finding?
Correct Answer: D
Rationale: Lichenification is thickened, hardened skin. A crust is a scab formed by dried serum. A papule is a raised solid lesion. Excoriation is a traumatic abrasion.
Question 4 of 5
The nurse is caring for a dark-skinned African American patient. Which site should the nurse use to evaluate for the presence or absence of cyanosis?
Correct Answer: B
Rationale: Nail beds show cyanosis as a bluish cast, reliable in dark skin where skin tone may mask changes.
Question 5 of 5
A patient is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing him the nurse notes that his right leg is shorter than his left leg; his right hip is noticeably deformed and he is in acute pain. Imaging does not reveal a fracture. Which of the following is the most plausible explanation for this patient's signs and symptoms?
Correct Answer: D
Rationale: Signs and symptoms of a traumatic dislocation include acute pain, change in positioning of the joint, shortening of the extremity, deformity, and decreased mobility. A subluxation would cause moderate deformity, or possibly no deformity. A contusion or strain would not cause obvious deformities.