ATI LPN
Questions on the Integumentary System Questions
Question 1 of 5
A patient recovering from 25% total body surface area burns has a low-grade fever. What should the nurse do to reduce this patient's risk of developing an infection?
Correct Answer: C
Rationale: The correct answer is C: Use sterile technique for all dressing changes. Sterile technique reduces the risk of introducing harmful microorganisms into the burn wound, thus decreasing the likelihood of infection. By maintaining a sterile environment during dressing changes, the nurse can help protect the patient's vulnerable skin and promote healing. A: Following contact precautions is important for preventing the spread of infection, but it does not directly address the risk of infection in the burn wound. B: Implementing protective isolation is unnecessary in this case as the patient's low-grade fever does not indicate the need for isolation. D: Administering prophylactic antibiotics is not recommended in this scenario as it can contribute to antibiotic resistance and is not necessary unless there is a confirmed infection present.
Question 2 of 5
Some people only 'burn' when exposed to the sun. The reason they do not tan is that:
Correct Answer: B
Rationale: The correct answer is B because melanocytes are responsible for producing melanin, the pigment that gives skin its color. If melanocytes are inactive, the skin cannot produce enough melanin to tan, resulting in burning instead. Choice A is incorrect because everyone has the gene for tanning. Choice C is incorrect because keratinocytes are not directly involved in the tanning process. Therefore, the only logical explanation for not tanning and only burning when exposed to the sun is due to inactive melanocytes.
Question 3 of 5
A male client who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should:
Correct Answer: A
Rationale: The correct answer is A - Turn him frequently. Turning the client frequently helps redistribute pressure and prevents pressure ulcers. This action relieves pressure on specific areas of the body, promoting circulation and reducing the risk of tissue damage. Applying moisturizing lotion (choice B) may help with skin hydration but does not address the root cause of pressure ulcers. Increasing protein intake (choice C) is important for healing but does not directly prevent pressure ulcers. Using a pressure-relieving mattress (choice D) is beneficial, but turning the client is essential for effective pressure ulcer prevention.
Question 4 of 5
During the acute phase of a burn, the nurse in-charge should assess which of the following?
Correct Answer: A
Rationale: Correct Answer: A: Circulatory status Rationale: 1. Assessment of circulatory status is crucial in the acute phase of a burn to monitor for potential shock. 2. Circulatory status helps determine tissue perfusion and oxygenation. 3. Impaired circulation can lead to further complications and affect overall recovery. Summary of Incorrect Choices: B: Pain level - Important but not the priority in the acute phase. Pain management can be addressed after ensuring circulatory stability. C: Nutritional status - Important for overall healing but not the immediate concern in the acute phase. D: Psychological state - Important for long-term recovery but not the priority in the acute phase when physical stability is crucial.
Question 5 of 5
A male client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?
Correct Answer: A
Rationale: The correct answer is A: Scale. In psoriasis, scales are a common secondary lesion due to the rapid turnover of skin cells. The scaling appears as silvery-white plaques on red, inflamed skin. Scales are formed by the accumulation of dead skin cells on the skin surface. Crust (B) forms from dried serum, blood, or pus and is not typically associated with psoriasis. Fissure (C) is a linear crack in the skin that may occur in psoriasis but is not a primary characteristic. Ulcer (D) is a full-thickness loss of skin tissue and is not a typical secondary lesion in psoriasis.