ATI LPN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
During an assessment, you note fever, fatigue, weakness, cold and clammy skin, nausea, vomiting, and diarrhea. The body is fighting infection by:
Correct Answer: B
Rationale: These signs fever, clammy skin, nausea reflect inflammation (Choice B), the body's initial infection fight, per pathophysiology. Antigen-antibody is specific immunity, later. Interferon targets viruses. Acquired immunity develops over time. Inflammation vasodilation, cytokine release causes symptoms, an LPN observation, making it the correct response.
Question 2 of 5
A 25-year-old woman with a minor laceration moans about arm pain after an accident with her son. Her expression of pain is possibly influenced by:
Correct Answer: D
Rationale: Pain expression varies. Worry about her son heightens anxiety, amplifying pain perception, per stress-pain links. Blood may shock but not sustain moaning. Culture influences but lacks context here. Relief reduces stress. Maternal concern drives intensity, an LPN note, making it the correct influence.
Question 3 of 5
A long-term care nurse cares for an older male who is withdrawn, quiet, and grimaces when touched. The most appropriate action is:
Correct Answer: B
Rationale: Grimacing and withdrawal suggest pain. Assessing causes e.g., arthritis guides care, per nursing process. Meds need basis. Repositioning delays. Notification follows assessment. Thorough evaluation ensures targeted relief, an LPN duty, making it the correct action.
Question 4 of 5
Which item should the nurse use first to assist in staging an ulcer on a patient with darkly pigmented skin?
Correct Answer: D
Rationale: Staging ulcers in darkly pigmented skin requires accurate visualization. A halogen light is used first, per the text, to enhance inspection by countering fluorescent light's blue tones, revealing subtle redness or discoloration. Measuring tape sizes wounds later. Cotton applicators assess depth, not initial staging. Sterile gloves ensure infection control but don't aid visibility. Proper lighting is critical for the first step inspection ensuring nurses correctly identify stages like nonblanchable erythema, making this the correct initial tool.
Question 5 of 5
Which nursing observation will indicate the wound healed by secondary intention?
Correct Answer: D
Rationale: Secondary intention, for wounds like burns, leaves severe scarring (Choice D), per the text, as open wounds fill with scar tissue, potentially impairing function. Minimal tissue loss and minimal scarring suit primary intention. Dark redness isn't typical. Severe scarring reflects the healing process's extent, a key observation nurses document, making this the correct indicator of secondary intention healing.