ATI RN
Skin Integrity and Wound Care Questions Questions
Question 1 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 2 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 3 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.
Question 4 of 5
Which abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider?
Correct Answer: C
Rationale: The correct answer is C, petechiae on the chest and abdomen. Petechiae are small pinpoint hemorrhages that can indicate a serious underlying medical condition such as thrombocytopenia or a bleeding disorder. It is important to discuss this immediately with the healthcare provider to determine the cause and initiate appropriate treatment. A: Dry, scaly patches on the face are likely related to skin issues and can be addressed during a routine dermatology visit. B: Numerous varicosities on both legs are common in older individuals and usually do not require urgent attention unless causing pain or other complications. D: Small dilated blood vessels on the face are typically cosmetic concerns and not urgent unless they are causing discomfort or affecting vision.
Question 5 of 5
A teenaged male patient who is on a wrestling team is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis?
Correct Answer: B
Rationale: The correct answer is B because papular, wheal-like lesions with white deposits on the hair shaft are characteristic of pediculosis (lice infestation). The white deposits are lice eggs (nits) attached to the hair shaft, indicating the presence of lice. This finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of lice. Sharing headgear can facilitate the transmission of lice from one person to another. Choice A is incorrect as ring-like rashes with red, scaly borders over the entire scalp are more indicative of ringworm (tinea capitis), a fungal infection, not pediculosis. Choice C is incorrect as patchy areas of alopecia with small vesicles and excoriated areas are more indicative of scalp folliculitis or herpes zoster, not pediculosis. Choice D is incorrect as red, hive-like papules and plaques with sharply circumscribed borders are