ATI LPN
Integumentary System Exam Questions Questions
Question 1 of 5
Assessment of a patients leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion?
Correct Answer: B
Rationale: The correct answer is B: Ulcer. An ulcer is a skin lesion characterized by the loss of skin tissue, resulting in an open sore. In this case, the presence of necrotic tissue deeper than the epidermis indicates tissue loss, consistent with an ulcer. A keloid is a raised scar, not an open sore like an ulcer. A fissure is a linear crack in the skin, different from a circular area of tissue loss. An erosion is a superficial loss of skin layers, not as deep as what is described in the scenario. Therefore, the presence of necrotic tissue deeper than the epidermis points towards an ulcer as the correct skin lesion.
Question 2 of 5
While changing the dressing on a burned arm the patient complains of feeling cold and having extreme pain. However, the patient asks the nurse to not apply so much pressure when wrapping gauze around the limb. What should these findings indicate to the nurse?
Correct Answer: C
Rationale: The correct answer is C: Encapsulated nerve endings in the arm are intact. This is indicated by the fact that the patient is experiencing extreme pain (associated with free nerve endings) but can still differentiate pressure sensation (associated with encapsulated nerve endings). If all nerves were damaged (Choice A), the patient would not feel any sensation. If free nerve endings were injured (Choice B), the patient would not feel pain. If encapsulated nerve endings were injured (Choice D), the patient would not be able to differentiate pressure sensation.
Question 3 of 5
A nurse is caring for a patient who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. Which of the following measures will best achieve these goals?
Correct Answer: A
Rationale: The correct answer is A: Encouraging the patient to turn from side to side and to assume a prone position. This measure is essential for preventing hip flexion contractures after a below-the-knee amputation. Turning from side to side and assuming a prone position help in maintaining proper positioning and preventing hip flexion contractures by stretching the hip extensors and preventing the hip from being in a prolonged flexed position. Choice B is incorrect because initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation may be too late to prevent contractures. Choice C is incorrect as minimizing movement of the flexor muscles of the hip can actually lead to contractures. Choice D is also incorrect as sitting in a chair for extended periods can promote hip flexion contractures.
Question 4 of 5
A patient who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team?
Correct Answer: D
Rationale: The correct answer is D: Promote the patient's highest possible level of function. The primary goal of a multidisciplinary rehabilitation team caring for a patient who has had an amputation is to help the patient achieve their maximum functional ability and independence. This goal involves various specialists working together to provide comprehensive care tailored to the patient's specific needs. Maximizing efficiency of care (A) is important but not the primary goal. Ensuring holistic healthcare (B) is valuable but not the primary focus. Facilitating adjustment to a new body image (C) is important, but the primary goal is to promote the patient's functional abilities.
Question 5 of 5
The nurse needs to send a specimen for a wound culture. What should the nurse do prior to obtaining the specimen?
Correct Answer: B
Rationale: The correct answer is B: Flush the wound bed with sterile saline. Prior to obtaining a wound culture specimen, flushing the wound bed with sterile saline helps remove debris and contaminants. This step ensures that the specimen collected is not contaminated, providing accurate culture results. Applying clean gloves (A) is important but does not directly impact the quality of the specimen. Cleansing the wound with antimicrobial solution (C) may interfere with the culture results by killing bacteria present. Keeping the wound open to air for several minutes (D) does not contribute to obtaining a clean specimen.