ATI LPN
Fundamentals of Nursing Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
A nurse is preparing to perform the physical assessment of a newly admitted patient. During which of the following components of the assessment should the nurse wear gloves?
Correct Answer: B
Rationale: Gloves are worn during skin examination if a rash or lesions are to be palpated. It is not normally necessary to wear gloves to palpate intact skin unless contact with body fluids is foreseeable.
Question 2 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 3 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 4 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.
Question 5 of 5
The nurse notes that a male patient is bald. What is the status of the hair follicles on the head of this patient?
Correct Answer: B
Rationale: Baldness occurs when hair follicles enter a prolonged resting phase and do not progress to the growth phase.