A nurse is reviewing the nursing care plan for a client for whom a stage 4 decubiti ulcer has been documented. Which of the following would the nurse expect to note on assessment of the client?

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Skin Integrity NCLEX Questions Questions

Question 1 of 5

A nurse is reviewing the nursing care plan for a client for whom a stage 4 decubiti ulcer has been documented. Which of the following would the nurse expect to note on assessment of the client?

Correct Answer: D

Rationale: Stage 4 pressure ulcers involve full-thickness tissue loss extending into muscle, bone, or supporting structures.

Question 2 of 5

The nurse is preparing to send a culture for a patient who has a possible herpes zoster infection on the chest. Which action is appropriate?

Correct Answer: A

Rationale: For lesions with vesicles or bullae, the lesion should be opened using sterile technique and a specimen obtained from the center of the lesion. Aspiration of bullae would present a risk of injury to the patient. Swabbing the area would be likely to result in obtaining normal skin flora rather than the infectious agent. Anaerobic cultures would be unnecessary for an infection on the skin of the chest and would unnecessarily increase the cost of the culture.

Question 3 of 5

While assessing a 25-year-old female, the nurse notes that the patient has hair on her lower abdomen. Earlier in the health interview, the patient stated that her menses are irregular. The nurse should suspect what type of health problem?

Correct Answer: C

Rationale: Some women with higher levels of testosterone have hair in areas generally thought of as masculine, such as the face, chest, and lower abdomen, which may indicate a hormonal imbalance when paired with irregular menses.

Question 4 of 5

Tissue damage from burn injury activates an inflammatory response that increases the patient's risk for:

Correct Answer: C

Rationale: The loss of skin as the primary barrier against microorganisms and activation of the inflammatory response cascades results in immunosuppression, placing the patient at an increased risk of infection. A systemic inflammatory response(SIRS) also increases the risk of acute kidney injury in the presence of poor tissue perfusion. Acute respiratory distress syndrome is also a potential complication, but the risk of infection is greater because of the loss of the skin barrier. Catecholamine release and gastrointestinal ischemia are the causes of stress ulcers.

Question 5 of 5

A patient with cancer is experiencing hair loss from chemotherapy treatments. Which term should the nurse use to document this finding?

Correct Answer: A

Rationale: Hair loss is called alopecia. Allopathy is a system of medicine. Ecchymosis is bruising. Keratopenia is not a medical term.

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