ATI LPN
NCLEX Questions on Integumentary System Questions
Question 1 of 5
A patient reports chronic itching of the ankles and cannot keep from continuously scratching them. The nurse will plan to implement interventions to decrease the risk for
Correct Answer: C
Rationale: Lichenification is likely to occur in areas where the patient scratches the skin frequently. Scratching is not a risk factor for skin atrophy, keloid formation, and varicosities.
Question 2 of 5
The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment is:
Correct Answer: C
Rationale: During initial fluid resuscitation, urine output helps guide fluid resuscitation needs. Measuring hourly intake and output is most effective in determining the needs for additional fluid infusion than is urine output alone. Blood urea nitrogen may be used to monitor volume status, but it is affected by the hyper-metabolic state seen after burns, so it is not the optimal measure of intravascular fluid status. Daily weight measures overall volume status, not just intravascular volume. Serum potassium is released with tissue damage and thus is not the optimum measure of intravascular fluid status.
Question 3 of 5
A 63-year-old patient is admitted with new onset fever; flulike symptoms; blisters over her arms, chest, and neck; and red, painful, oral mucous membranes. The patient should be further evaluated for which possible non–burn injured skin disorder?
Correct Answer: A
Rationale: Patients with toxic epidermal necrolysis, Stevens-Johnson Syndrome(SJS), and erythema multiforme present with acute onset fever and flulike symptoms, with erythema and blisters developing within 24 to 96 hours, skin and mucous membranes slough, resulting in a significant and painful partial-thickness injury. Staphylococcal scalded skin syndrome presents predominantly in children. Necrotizing soft tissue infection results from rapidly invasive bacterial infections. Graft versus host disease is not logical given the clinical information provided.
Question 4 of 5
A patient with second-degree burns is concerned about skin repair. What should the nurse include when explaining the primary function of the epidermal layers of the skin?
Correct Answer: B
Rationale: The epidermis, especially the stratum corneum, acts as a primary barrier against pathogens.
Question 5 of 5
A nurse is performing a shift assessment on an elderly patient who is recovering after surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the patient is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this patient is likely demonstrating symptoms of what complication?
Correct Answer: C
Rationale: Fat embolism syndrome occurs most frequently in young adults and elderly patients who experience fractures of the proximal femur (i.e., hip fracture). Presenting features of fat embolism syndrome include hypoxia, tachypnea, tachycardia, and pyrexia. The respiratory distress response includes tachypnea, dyspnea, wheezes, precordial chest pain, cough, large amounts of thick, white sputum, and tachycardia. Avascular necrosis (AVN) occurs when the bone loses its blood supply and dies. This does not cause coughing. Complex regional pain syndrome does not have cardiopulmonary involvement.