ATI LPN
Integumentary System Questions Questions
Question 1 of 5
For a client diagnosed with lumbar strain, which nursing interventions should be included in the plan of care?
Correct Answer: A
Rationale: Step 1: Assessing pain on a 1-to-10 scale is crucial in managing lumbar strain as it helps determine the severity and effectiveness of interventions. Step 2: Pain assessment guides treatment adjustments and ensures optimal pain control for the client. Step 3: Administering pain medication PRN without proper assessment may lead to overmedication or under-treatment. Step 4: Providing a regular bedpan for elimination is not directly related to managing lumbar strain. Step 5: Assessing surgical dressing every four hours is not necessary for a client with lumbar strain unless there are specific indications.
Question 2 of 5
The client admitted with a diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement?
Correct Answer: B
Rationale: The correct answer is B: Ensure the weights of the Buck's traction are off the floor and hang freely. This intervention is essential to maintain proper traction and alignment of the fractured hip, which can help alleviate pain. When the weights are not hanging freely, the traction may not be effective, causing increased pain and potential complications. Explanation of why the other choices are incorrect: A: Adjusting the PCA machine for a lower dose may temporarily relieve pain, but it does not address the underlying issue of ineffective traction. C: Raising the head and foot of the bed may provide comfort but does not directly address the issue of inadequate traction. D: Turning the client on the affected leg can worsen the fracture and cause more pain, contrary to the goal of relieving pain in a client with a fractured hip in Buck's traction.
Question 3 of 5
Two unlicensed assistive personnel (UAP) are using the transfer board to move the client from the bed to the wheelchair. Which action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A. The nurse should take no action because using a transfer board to move a client from the bed to the wheelchair is an appropriate and safe procedure when performed correctly by UAPs. Using a transfer board helps in ensuring a smooth and safe transfer without causing harm to the client. Instructing the UAPs not to use a transfer board (choice B) would be incorrect as it is a useful tool for transferring clients safely. Using a bed scale sling to move the client (choice C) is not appropriate for transferring the client from the bed to the wheelchair. Requesting the UAPs to stop and come to the nurse's station (choice D) is unnecessary and interrupts the transfer process.
Question 4 of 5
The emergency department nurse is caring for a 6-year-old child with a fractured forearm and suspects the injury is the result of abuse. Which x-ray finding would confirm the suspicions for the nurse?
Correct Answer: B
Rationale: The correct answer is B: A spiral fracture. Spiral fractures are often associated with twisting injuries, which are commonly seen in cases of child abuse. The spiral nature of the fracture indicates a rotational force applied to the bone, consistent with non-accidental trauma. A: A single transverse fracture is not specific to abuse and can occur from accidental falls. C: A greenstick fracture is an incomplete fracture commonly seen in children due to their bone structure, not necessarily indicative of abuse. D: A comminuted fracture, while severe, does not specifically point towards abuse as it can result from high-impact accidents. In summary, the presence of a spiral fracture in a young child raises suspicion of non-accidental trauma due to its characteristic mechanism of injury.
Question 5 of 5
Which situation is an example of the nurse fulfilling the role of client advocate?
Correct Answer: C
Rationale: The correct answer is C because contacting the healthcare provider when pain relief is not obtained demonstrates advocacy for the client's well-being. The nurse is advocating for the client's right to adequate pain management. Bringing pain medication when due (A) is part of standard nursing care, not necessarily advocacy. Collaborating with other disciplines (B) is important for holistic care but doesn't directly relate to advocating for the client. Teaching the client to ask for medication (D) is empowering but not necessarily advocating for the client in this context.