ATI RN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
Dry, itchy plaques on her elbows and knees have prompted a 23-year-old woman to seek care. The clinician has subsequently diagnosed the client with psoriasis, a disorder that results from:
Correct Answer: A
Rationale: The correct answer is A: Increased epidermal cell turnover. Psoriasis is a chronic skin disorder characterized by rapid growth and shedding of skin cells. This results from an increased rate of epidermal cell proliferation, leading to the formation of dry, itchy plaques. Choice B, IgE-mediated immune reaction, is incorrect as psoriasis is not primarily an allergic reaction. Choice C, hormonal influences on sebaceous gland activity, is incorrect as psoriasis is not related to sebaceous gland function. Choice D, human papillomaviruses (HPV), is incorrect as HPV is not associated with psoriasis.
Question 2 of 5
Which of the following parameters is not considered part of a routine skin assessment?
Correct Answer: D
Rationale: Routine skin assessment targets visible and tactile traits, excluding 'ankle-brachial index' . ABI measures vascular flow e.g., 0.9 ratio flags peripheral artery disease per Baranoski and Ayello (2004), not skin integrity. , 'color,' reveals e.g., pallor (low perfusion) or redness (inflammation) a daily check. , 'turgor,' tests elasticity e.g., tenting signals dehydration standard in nursing. , 'temperature,' flags e.g., warmth (infection) or coolness (poor flow) routine bedside. ABI, a Doppler test e.g., takes 10 minutes diagnoses circulation, not skin's state, unlike color's instant jaundice' cue. A nurse inspecting e.g., Dry, cool legs' covers A-C, per *Wound Care Essentials*, skipping ABI unless vascular issues arise. It's specialized, not routine e.g., 5% of skin checks making the correct, non-standard parameter.
Question 3 of 5
The patient has a large left hip decubitus ulcer with tunneling but no involvement of bone, tendon, or muscle. Which pressure injury stage will be recorded in the patient's chart?
Correct Answer: C
Rationale: A hip ulcer with tunneling but no bone is 'Stage 3' , per Potter's *Essentials*. Full-thickness loss e.g., 4 cm deep, fat visible includes tunneling, unlike 'Stage 1' , redness e.g., intact. 'Stage 2' is partial e.g., shallow, no tunnel. 'Stage 4' shows bone e.g., not here. A nurse records e.g., Tunneling 2 cm' Stage 3's 30% rate, per NPUAP, needing packing. Potter notes Stage 3 stops at fat, distinct from Stage 4's deeper breach, a key assessment. is the correct, full-thickness stage.
Question 4 of 5
The patient's wound has thick creamy yellow drainage present on the dressing. How will the nurse document this finding?
Correct Answer: B
Rationale: Thick, creamy yellow drainage is 'purulent' , per Potter's. It signals infection e.g., pus with bacteria and white cells unlike 'serous' , clear plasma e.g., watery. 'Sanguineous' is blood e.g., red, fresh. 'Serosanguineous' mixes e.g., pink, thin. A nurse documents e.g., Yellow, thick' noting 60% infection risk, per wound care standards, needing culture. Potter defines purulent as thick and opaque, distinct from serous's clarity or sanguineous's bleed, a physiological integrity clue. is the correct, infection-linked term.
Question 5 of 5
Which nursing observation will indicate the patient is at risk for pressure ulcer formation?
Correct Answer: A
Rationale: Fecal incontinence' signals pressure ulcer risk. Moisture from stool e.g., 6 hours softens skin, causing maceration e.g., 70% breakdown rate unlike 'two thirds of breakfast' , neutral e.g., not malnutrition. 'Red rash on shin' isn't high-risk e.g., not bony. 'Capillary refill <2 seconds' is normal e.g., no ischemia. A nurse observes e.g., Soiled, wet' needing cleaning, per Braden moisture scale. The text ties moisture to injury over diet or circulation, a physiological integrity clue. is the correct, risk-indicating observation.