ATI RN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
An older adult client is admitted with pneumonia. Which manifestations would the nurse expect to find when assessing this client? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Hemoptysis. In pneumonia, hemoptysis (coughing up blood-tinged sputum), is a common symptom due to inflammation and infection in the lungs. It is caused by the destruction of lung tissue and blood vessels. Increased appetite (B) is unlikely as pneumonia typically causes a decreased appetite due to feeling unwell. Cough (C) is a common manifestation of pneumonia, but it is not specific to pneumonia alone. Tachypnea (D) is also a common symptom of pneumonia due to the body's attempt to increase oxygen intake, but it is not as specific as hemoptysis in this context.
Question 2 of 5
List the pathophysiology concepts related to the onset of sepsis in sequential order.
Correct Answer: A
Rationale: The correct sequence for the pathophysiology of sepsis onset is as follows: 1. Macrophage-producing cytokines are released. 2. Endotoxin released by microorganisms triggers an inflammatory response. 3. Neutrophils arrive and multiply, leading to capillary occlusion. 4. Vasodilation occurs with increased capillary permeability and fluid leak. Macrophage cytokines initiate the cascade of events by signaling the immune response. Endotoxin release exacerbates inflammation. Neutrophil accumulation causes capillary blockage. Vasodilation and increased permeability follow, leading to septic shock. Other choices are incorrect as they do not follow the correct sequence of events in sepsis pathophysiology.
Question 3 of 5
The nurse is providing teaching to parents about urinary tract infections (UTIs) in preschool children. The nurse should inform the parents that which of the following are common symptoms of UTI in this age group? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Urinary urgency. In preschool children, common symptoms of UTI include urinary urgency due to the irritation of the bladder lining by the infection. Elevated blood pressure is not a common symptom of UTI in this age group. Dysuria, or painful urination, can also be a symptom but is less common in preschool children. Fever is a common symptom of UTI, but it is not specific to this age group as it can occur in various infections. Therefore, the most specific and common symptom of UTI in preschool children is urinary urgency.
Question 4 of 5
The nurse is caring for a client who is admitted to the unit with tuberculosis (TB). Which type of isolation room is most appropriate?
Correct Answer: B
Rationale: The correct answer is B: Isolation room with an anteroom and negative airflow. This is appropriate for TB as it prevents contaminated air from escaping the room, reducing the risk of transmission. Negative airflow ensures air flows into the room, capturing and containing infectious particles. A: Positive airflow would allow contaminated air to escape. C: Normal airflow may not contain infectious particles effectively. D: Normal airflow could lead to potential spread of TB outside the room.
Question 5 of 5
Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of concern to the nurse?
Correct Answer: C
Rationale: The correct answer is C because skin wrinkling with tenting on both hands in an older patient with bacterial pneumonia is concerning for dehydration. Dehydration can exacerbate the pneumonia and lead to complications. Skin turgor is a key indicator of hydration status. Brown macules, allergic rashes, longitudinal nail ridges, and sparse scalp hair are not directly related to dehydration or bacterial pneumonia in this context. Brown macules may be age-related skin changes, allergic rashes indicate hypersensitivity reactions, longitudinal nail ridges can be a normal part of aging, and sparse scalp hair could be due to various factors unrelated to the pneumonia.