ATI RN
Fundamentals of Nursing Skin Integrity Questions Questions
Question 1 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 2 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.
Question 3 of 5
Which assessment finding indicates to the nurse that the patient is at high risk for developing a pressure injury?
Correct Answer: A
Rationale: A 'serum total protein level of 4.6 g/dL' flags high pressure injury risk, per Potter's *Essentials*. Normal is 6-8 g/dL; 4.6 e.g., 30% below causes edema, impairing oxygen delivery (e.g., 10% less to tissues), softening skin for breakdown. 'Braden Scale score of 22' is low risk e.g., 18 or below for elders signals danger, 22 is safe. 'Cetirizine 5 mg daily' is an antihistamine e.g., no skin integrity link. 'Fasting glucose 84 mg/dL' is normal e.g., 70-100, no risk. A nurse assessing e.g., swollen legs links low protein to 50% higher ulcer odds, per nutrition studies, needing dietary boost. is the correct, critical finding.
Question 4 of 5
Which intervention will the nurse use for an abscessed leg wound?
Correct Answer: C
Rationale: For an abscessed leg wound, 'warm moist compresses' suit, per Potter's . Heat e.g., 38°C boosts blood flow (e.g., 20% more), drawing pus e.g., drains in 24 hours unlike 'sitz baths' , for perineum e.g., post-hemorrhoid. 'Cold compresses' reduce swelling e.g., not drainage. 'Epsom soaks' relax muscles e.g., not abscess-specific. A nurse applies e.g., Warm cloth 15 min' aiding resolution (e.g., 70% faster), per heat therapy principles. Potter notes warmth's circulatory aid, a physiological integrity boost, making the correct, therapeutic choice.
Question 5 of 5
The patient has a deep decubitus ulcer on the heel that is covered in thick necrotic tissue. Which term will the nurse use to describe the ulcer in the patient's medical record?
Correct Answer: D
Rationale: A heel ulcer with thick necrosis is 'unstageable' , per Potter's. Depth's hidden e.g., eschar blocks view unlike 'fluctuant' , shifting e.g., abscess fluid. 'Indurated' is hard e.g., not necrotic. 'Macerated' is wet e.g., moisture breakdown. A nurse writes e.g., Black cover' unstageable's 15% rate, per NPUAP, needing debridement. Potter notes obscured depth blocks staging e.g., not Stage 4 till cleared a physiological integrity issue. is the correct, assessment term.