ATI RN
Skin Integrity and Wound Care NCLEX Questions Questions
Question 1 of 5
A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention will the nurse include in the initial plan of care?
Correct Answer: B
Rationale: The correct answer is B: Immobilization of the left leg. In acute osteomyelitis, immobilization of the affected limb helps reduce movement and prevent further damage or spread of infection. Immobilization also promotes healing and allows for effective administration of regional antibiotic irrigation. Quadriceps-setting exercises (choice A) may be considered later in the treatment plan to prevent muscle atrophy but are not appropriate initially. Positioning the left leg in flexion (choice C) can worsen the infection by limiting circulation and exacerbating pain. Assisted weight-bearing ambulation (choice D) can increase pressure on the affected bone and hinder healing.
Question 2 of 5
Which action will the nurse take when caring for a patient with osteomalacia?
Correct Answer: A
Rationale: The correct answer is A: Teach about the use of vitamin D supplements. Osteomalacia is a condition characterized by a deficiency of vitamin D, leading to weak and soft bones. Vitamin D supplements help in improving calcium absorption and bone mineralization. By educating the patient about the importance of vitamin D supplements, the nurse addresses the root cause of osteomalacia. Choice B is incorrect because while weight-bearing exercise is beneficial for bone health, it does not directly address the vitamin D deficiency seen in osteomalacia. Choice C is incorrect as bisphosphonates are typically used in conditions like osteoporosis, not osteomalacia. Choice D is incorrect as sunscreen use, although important for skin health, does not address the underlying vitamin D deficiency in osteomalacia.
Question 3 of 5
The clinic health care worker notices that a client has a fungal infection on her nails that looks like the fungus is digesting the nail keratin. The nail appears opaque and white in color. The client states she has had this for years. The health care worker suspects the client has:
Correct Answer: C
Rationale: The correct answer is C: Onychomycosis. This is a fungal infection of the nail caused by dermatophytes, yeasts, or molds. In this case, the description of the nail appearing opaque and white, with the fungus appearing to digest the keratin, is consistent with onychomycosis. The fact that the client has had this for years also aligns with the chronic nature of onychomycosis. Explanation for why other choices are incorrect: A: Candidiasis is a fungal infection caused by Candida species, typically affecting mucous membranes or skin folds, not nails. B: Cellulitis is a bacterial infection involving the deeper layers of the skin, not related to fungal nail infections. D: Tinea corporis is a fungal infection of the skin, commonly known as ringworm, not specific to nails.
Question 4 of 5
What process accounts for the damaging effects of the sun's radiation?
Correct Answer: C
Rationale: The correct answer is C because sun radiation can cause damage to the DNA in epidermal cells, leading to mutations and skin cancer. Additionally, sun exposure can generate free radicals, which can further damage skin cells. Autoimmune response (A) is not related to the sun's damaging effects. Compensatory increases in melanin production (B) is a protective response to sun exposure, not a direct cause of damage. Hyperkeratinization and lesion formation (D) are not specific processes related to sun radiation damage.
Question 5 of 5
A client has just received the diagnosis of malignant melanoma, stage 3B. He asks the nurse what this means. The nurse should respond relaying which of the following information? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A because malignant melanoma is indeed a very rapid growing and aggressive cancer. This information is crucial for the client to understand the seriousness of the diagnosis and the need for prompt and aggressive treatment. Explanation of why other choices are incorrect: B: This cancer usually extends wide and deep but rarely metastasize - This statement is incorrect because malignant melanoma is known to have a high potential for metastasis. C: This cancer is mainly contained to the head and neck area - This statement is incorrect because melanoma can occur on any part of the body, not just limited to the head and neck. D: Your cancer has grown into the deep tissues and quite likely into lymph nodes (stage 3B) - While this choice provides some accurate information about the staging of the cancer, it does not fully address the client's question about the nature of malignant melanoma.