ATI LPN
Integumentary System Multiple Choice Questions and Answers Questions
Question 1 of 5
The client diagnosed with chronic otitis media is scheduled for a mastoidectomy. Which discharge teaching should the nurse discuss with the client?
Correct Answer: D
Rationale: The correct answer is D: Do not allow water to enter the ear for six (6) weeks. This instruction is essential post-mastoidectomy to prevent infection and promote healing. Water exposure can introduce bacteria, leading to complications. Option A is incorrect as the Valsalva maneuver should be avoided to prevent pressure changes in the ear. Option B is incorrect as hearing can improve after mastoidectomy. Option C is incorrect as ophthalmic drops are not indicated for ear care.
Question 2 of 5
The nurse is admitting a client diagnosed with primary adrenal cortex insufficiency (Addison's disease). Which clinical manifestations should the nurse expect to assess?
Correct Answer: C
Rationale: The correct answer is C: Bronze pigmentation, hypotension, and anorexia. Primary adrenal cortex insufficiency (Addison's disease) is characterized by decreased production of cortisol and aldosterone. Bronze pigmentation is due to increased melanocyte-stimulating hormone. Hypotension is a result of aldosterone deficiency leading to sodium and water loss. Anorexia can occur due to decreased cortisol levels affecting glucose metabolism. A: Moon face, buffalo hump, and hyperglycemia are manifestations of Cushing's syndrome, which is excessive cortisol production. B: Hirsutism, fever, and irritability are not typical manifestations of Addison's disease. D: Tachycardia, bulging eyes, and goiter are signs of hyperthyroidism, not adrenal insufficiency.
Question 3 of 5
The client is one (1) hour postoperative thyroidectomy. Which intervention should the nurse implement?
Correct Answer: A
Rationale: The correct answer is A: Check the posterior neck for bleeding. This intervention is crucial post-thyroidectomy to monitor for any signs of bleeding, which can be life-threatening. Checking for bleeding is a priority as it can lead to airway compromise and requires immediate intervention. Assessing for Chvostek's sign (B) is unrelated to a thyroidectomy and is used to detect hypocalcemia. Monitoring serum calcium level (C) is important but not as immediate as checking for bleeding. Changing the surgical dressing (D) is important for wound care but does not address the critical need to assess for bleeding.
Question 4 of 5
The client has developed atrial fibrillation, with a ventricular rate of 150 beats/minute. The nurse should assess the client for which associated signs and/or symptoms?
Correct Answer: C
Rationale: The correct answer is C: Hypotension and dizziness. In atrial fibrillation with a rapid ventricular rate, the heart is unable to effectively pump blood, leading to decreased cardiac output. This can result in hypotension and dizziness due to inadequate perfusion of tissues. Flat neck veins (choice A) are not typically associated with atrial fibrillation. Nausea and vomiting (choice B) may occur in some cases but are not the primary signs and symptoms. Hypertension and headache (choice D) are less likely to occur with atrial fibrillation and a rapid ventricular rate.
Question 5 of 5
The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action?
Correct Answer: B
Rationale: The clear nasal drainage post-hypophysectomy could indicate a cerebrospinal fluid (CSF) leak. Testing the drainage for glucose can help differentiate between CSF and nasal secretions. CSF contains glucose, so if the drainage tests positive for glucose, it confirms a CSF leak. This is important because a CSF leak requires prompt intervention to prevent complications. Lowering the head of the bed (choice A) may promote CSF leakage. Obtaining a culture (choice C) is not the initial priority, as identifying the type of fluid is crucial first. Continuing to observe (choice D) delays necessary action if a CSF leak is present.