ATI RN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
A patient complains of shoulder pain when the nurse moves the patient’s arm behind the back. Which question should the nurse ask?
Correct Answer: B
Rationale: The correct answer is B: Do you have difficulty when you are putting on a shirt? This question is relevant because it specifically addresses the motion that triggers the patient's shoulder pain. It helps to assess the range of motion and identify any limitations or discomfort during activities involving arm movement behind the back. A: Are you able to feed yourself without difficulty? - While this question addresses arm movement, it does not specifically target the motion that triggers the pain. C: Are you able to sleep through the night without waking? - This question does not directly relate to the shoulder pain triggered by arm movement behind the back. D: Do you ever have trouble lowering yourself to the toilet? - This question does not address the specific movement causing the shoulder pain and is not as relevant for assessing the patient's condition.
Question 2 of 5
Which discharge instruction will the emergency department nurse include for a patient with a sprained ankle?
Correct Answer: C
Rationale: The correct answer is C: Use pillows to elevate the ankle above the heart. Elevating the ankle helps reduce swelling by promoting venous return and decreasing fluid accumulation. This position also helps with pain management. Choice A is incorrect as wrapping the ankle too loosely may not provide adequate support. Choice B is incorrect because heat can increase swelling and inflammation. Choice D is incorrect as moving the ankle through the range of motion can worsen the injury.
Question 3 of 5
A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing assessment finding indicates a potential complication of the fracture?
Correct Answer: B
Rationale: The correct answer is B because a distended abdomen and absent bowel sounds can indicate internal bleeding or organ damage, common complications of pelvic fractures. This suggests potential abdominal compartment syndrome or intra-abdominal hemorrhage. Choices A and C are typical symptoms of a pelvic fracture and do not specifically indicate a complication. Choice D may be common due to the impact of the crash but does not directly indicate a complication like internal bleeding.
Question 4 of 5
Which action will the nurse include in the plan of care for a patient who had a cemented right total knee arthroplasty?
Correct Answer: D
Rationale: The correct answer is D because starting progressive knee exercises is essential for regaining strength and mobility post total knee arthroplasty. This will help prevent stiffness and promote healing. Choice A is incorrect as full extension is crucial to prevent contractures. Choice B is incorrect because keeping the knee flexed can lead to stiffness and limited range of motion. Choice C is incorrect as weight-bearing is usually encouraged early on to promote healing and prevent muscle atrophy.
Question 5 of 5
A patient who arrives at the emergency department experiencing severe left knee pain is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for
Correct Answer: A
Rationale: The correct answer is A: a knee immobilizer. This is important to prevent further injury and stabilize the knee joint after a patellar dislocation. Immobilization helps in reducing pain, preventing more dislocations, and promoting healing. Gentle knee flexion (B) may worsen the dislocation. Monitored anesthesia care (C) is not necessary for patient teaching. Physical activity restrictions (D) may be important but are not the immediate focus of patient teaching for a patellar dislocation.