ATI LPN
Questions on the Integumentary System Questions
Question 1 of 5
After educating a caregiver of a home care client, a nurse assesses the caregiver's understanding. Which statement indicates that the caregiver needs additional education?
Correct Answer: B
Rationale: The correct answer is B because massaging a red and tender tailbone with baby oil can worsen the condition by causing further irritation or infection. Step 1: Identify the potential harm - Massaging a red and tender area can aggravate the skin. Step 2: Analyze the situation - Inflamed skin needs gentle care, not friction. Step 3: Apply critical thinking - Providing the wrong intervention can lead to adverse outcomes. Summary: Choices A, C, and D are all appropriate interventions for promoting the client's well-being, while choice B poses a risk of harm.
Question 2 of 5
A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication?
Correct Answer: B
Rationale: The correct answer is B: Urine output of 20 mL/hr. This finding indicates inadequate renal perfusion, potentially leading to acute kidney injury, a common complication in burn patients. Low urine output can result from decreased cardiac output and hypovolemia due to fluid loss from burns. In contrast, choices A, C, and D are not directly related to potential complications in burn patients. Choice A (PaO₂ of 80 mm Hg) is within the normal range and does not specifically indicate a complication. Choice C (productive cough with white pulmonary secretions) could suggest a respiratory infection but is not a common complication in burn patients. Choice D (core temperature of 100.6°F) is slightly elevated but not a significant concern compared to the potential impact of inadequate renal perfusion.
Question 3 of 5
When taking the health history of an older adult, the nurse discovers that the patient has worked in the landscaping business for 40 years. Which clinical manifestation should the nurse teach the patient to self-assess for?
Correct Answer: C
Rationale: Rationale: C: Erythema is the correct answer because prolonged sun exposure in landscaping can lead to skin redness. Sunburn and skin damage are common in outdoor workers. A: Vitiligo is an autoimmune condition causing skin depigmentation, not directly related to sun exposure. B: Alopecia is hair loss, not a direct result of sun exposure. D: Actinic keratosis is a precancerous skin lesion due to sun exposure, but erythema is more common in this scenario.
Question 4 of 5
The nurse is caring for a patient diagnosed with furunculosis. Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP)?
Correct Answer: D
Rationale: The correct answer is D: Cleaning the skin with antimicrobial soap. This task can be safely delegated to UAP as it does not involve any invasive or complex procedures. It is within the scope of practice for UAP and is an important aspect of managing furunculosis to prevent infection spread. Applying antibiotic cream (choice A) involves assessing the skin and determining the appropriate treatment, which requires nursing judgment. Obtaining cultures (choice B) requires specific training and knowledge to collect samples correctly. Evaluating personal hygiene (choice C) involves assessing and analyzing the patient's hygiene practices, which requires nursing assessment skills. Cleaning the skin with antimicrobial soap is a straightforward task that UAP can perform under the supervision of a nurse.
Question 5 of 5
The paraplegic client is being admitted to a medical unit from home with a stage IV pressure ulcer over the right ischium. Which assessment tool should be completed on admission to the hospital?
Correct Answer: A
Rationale: The correct answer is A: Complete the Braden Scale. This tool assesses the risk of pressure ulcers by evaluating factors such as sensory perception, moisture, activity, mobility, nutrition, and friction/shear. It is crucial to complete this assessment on admission to determine the client's risk level and develop appropriate prevention strategies. B: Monitoring the client on a Glasgow Coma Scale is not relevant in this scenario as it assesses the level of consciousness, not pressure ulcer risk. C: Assessing for Babinski's sign is a neurological assessment and not related to pressure ulcer risk assessment. D: Initiating a Brudzinski flow sheet is not a recognized tool for pressure ulcer risk assessment and is not relevant in this context.