ATI RN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
A patient is receiving IV antibiotics at home to treat chronic osteomyelitis of the left femur. The nurse identifies a need for additional teaching related to health maintenance when the nurse finds that the patient
Correct Answer: C
Rationale: The correct answer is C because the inability to plantar flex the foot on the affected side indicates a potential complication related to the osteomyelitis. This could suggest nerve damage, muscle weakness, or worsening infection. Proper plantar flexion is essential for mobility and muscle function. Incorrect choices: A: Frustration with treatment length is common but does not directly impact health maintenance. B: Taking and recording oral temperature is a routine monitoring activity and shows the patient is engaged in self-care. D: Using crutches to avoid weight bearing is a protective measure to prevent further damage to the affected leg and is appropriate for osteomyelitis management.
Question 2 of 5
A nurse who works on the orthopedic unit has just received change-of-shift report. Which patient should the nurse assess first?
Correct Answer: B
Rationale: The correct answer is B because urinary retention post-laminectomy can lead to serious complications like bladder distension and renal impairment. Assessing and addressing the patient's voiding status promptly is crucial. Choices A, C, and D all have important issues but do not pose immediate risks to the patient's physiological stability compared to urinary retention.
Question 3 of 5
A teenager reports ugly warts that have invaded her hands. She wants them gone before prom season. The nurse will likely be explaining which of the following treatment measures to this teenager?
Correct Answer: B
Rationale: The correct answer is B: Applying a keratolytic agent like salicylic acid. Salicylic acid is an effective treatment for warts as it helps remove the outer layer of the skin, allowing the wart to gradually diminish. Steroid creams (choice A) are not typically used for warts. Pulling the wart off with tweezers (choice C) can be painful and may lead to infection. Cryotherapy (choice D) should be done by a healthcare professional as it involves freezing the wart with liquid nitrogen. Salicylic acid is a safe and effective over-the-counter treatment for warts, making it the best choice for the teenager seeking a quick resolution before prom season.
Question 4 of 5
A thermal burn described as involving the entire epidermis and dermis is classified as:
Correct Answer: D
Rationale: The correct answer is D: Full-thickness second degree. This classification indicates a burn that extends through the entire epidermis and dermis. The term "full-thickness" implies involvement of both layers. Choice A (full third degree) is incorrect as it implies deeper tissue involvement beyond the dermis. Choice B (deep first degree) is incorrect as it suggests involvement of only the epidermis and deeper layers. Choice C (partial second degree) is incorrect because it implies involvement of only part of the dermis, not the entire thickness. Therefore, the most accurate classification for a burn involving the entire epidermis and dermis is full-thickness second degree.
Question 5 of 5
A woman has just delivered a child with a hemangioma on his right cheek area. The mother clutches the nurse and asks, “What is that thing on his face?” The nurse will respond with which of the following facts? Select all that apply.
Correct Answer: A
Rationale: Rationale: 1. Hemangiomas are commonly referred to as "strawberry birthmarks" due to their red, raised appearance. 2. They are common in newborns and usually appear within the first few weeks of life. 3. Hemangiomas typically grow in size initially, then gradually shrink over time without any treatment. 4. Most hemangiomas do not cause any health issues and are not cancerous. 5. Therefore, choice A is correct as it accurately explains the nature and commonality of hemangiomas in newborns. Other choices are incorrect as they do not align with the typical characteristics and outcomes of hemangiomas, such as rapid growth followed by regression, permanence, or the need for close monitoring in case of ulceration.