ATI RN
Fundamentals of Nursing Skin Integrity Questions Questions
Question 1 of 5
A patient with muscular dystrophy is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
Correct Answer: A
Rationale: The correct answer is A: Logroll the patient every 2 hours. This is crucial for a patient with muscular dystrophy due to their weakened muscles, which can lead to pressure ulcers if not repositioned regularly. Logrolling helps prevent skin breakdown and maintains proper body alignment. Incorrect choices: B: Assisting with ambulation is not appropriate for a patient with muscular dystrophy as they have muscle weakness and mobility limitations. C: Discussing genetic testing may be important for diagnosis but is not a priority during hospitalization for pneumonia. D: Teaching about muscle biopsy is not directly related to the immediate care needs of a patient with pneumonia and muscular dystrophy.
Question 2 of 5
Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/LVN) (select the one that does not apply)?
Correct Answer: D
Rationale: The correct answer is D because LPN/LVNs are not typically trained to explain medical tests to patients. LPN/LVNs can administer patch testing, interview patients, and apply sterile dressings under the supervision of a healthcare provider. Explaining medical tests requires a higher level of knowledge and skill, usually performed by registered nurses or healthcare providers. Therefore, delegating the task of explaining potassium hydroxide testing to an LPN/LVN would not be within their scope of practice.
Question 3 of 5
A teenager with rosacea should be educated that in addition to the “blush appearance” on the face, she should also assess for which of the following additional complications? Select all that apply.
Correct Answer: C
Rationale: The correct answer is C: Edema of the eyelids. This is correct because rosacea can sometimes lead to ocular complications, such as blepharitis, conjunctivitis, and edema of the eyelids. These conditions can affect the eyes of individuals with rosacea. Rationale: - A: Inflamed and tender axillary lymph nodes are not typically associated with rosacea. This is an incorrect choice. - B: While eye problems are a potential complication of rosacea, edema of the eyelids is a more specific and direct complication that should be assessed for. - D: Large abscesses on the upper arms and neck are not commonly associated with rosacea. This choice is incorrect.
Question 4 of 5
A child has been admitted to the burn unit after pulling a pan of hot water off the stove. Given the fact that there is primarily second- and third-degree burns, the health care worker should prioritize care to focus on which of the following? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Focus on replacing fluids that have been lost from the vascular, interstitial, and cellular compartments. In burn injuries, there is a significant loss of fluids due to damage to the skin barrier. Prioritizing fluid replacement helps prevent hypovolemic shock and maintains adequate tissue perfusion. This is crucial in managing burn patients to prevent complications like organ failure. Choices B, C, and D are incorrect: B: Assessing for airway compromise is important but not the top priority in this scenario. Fluid resuscitation takes precedence in managing burn injuries. C: Maintaining a sterile field is important for infection prevention but is not the immediate priority over fluid replacement. D: Withholding nutrition is not recommended as burn injuries increase the body's metabolic demands. Providing adequate nutrition supports healing and recovery, so withholding food can be detrimental. In summary, fluid replacement is prioritized in burn injuries to prevent shock and maintain tissue perfusion.
Question 5 of 5
Which of the following changes are normal in the elderly population? Select all that apply.
Correct Answer: A
Rationale: Rationale for choice A being correct: The dermis and epidermis thin as one ages due to decreased collagen and elastin production. This leads to fragile skin, increased risk of injury, and slower wound healing. Summary of why other choices are incorrect: B: Subcutaneous tissue typically decreases with age, leading to less padding. C: Blood vessels tend to become less elastic and more rigid, not thicker. D: Older adults often experience muscle and fat loss, rather than increased padding on the buttocks.