ATI LPN
Skin Integrity Nursing Questions Questions
Question 1 of 5
The client has had an enucleation of the left eye. Which intervention should the nurse implement?
Correct Answer: B
Rationale: Referral for an ocular prosthesis addresses cosmetic and psychological needs post-enucleation, a standard intervention.
Question 2 of 5
The 26-year-old male client in the PACU has a heart rate of 110 and a rising temperature, and complains of muscle stiffness. Which interventions should the nurse implement? Select all apply.
Correct Answer: B
Rationale: Muscle stiffness and rising temperature suggest malignant hyperthermia, treatable with cooling measures and dantrolene.
Question 3 of 5
The nurse is discharging a client diagnosed with diabetes insipidus. Which statement made by the client warrants further intervention?
Correct Answer: B
Rationale: Desmopressin (DDAVP) for DI should be stored properly but taken as prescribed, not just mornings; this suggests misunderstanding.
Question 4 of 5
A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for?
Correct Answer: B
Rationale: Cardiogenic shock increases ischemia risk, potentially causing ventricular dysrhythmias.
Question 5 of 5
The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom develops?
Correct Answer: A
Rationale: Shakiness is a classic sign of hypoglycemia, indicating the need for a quick-acting glucose source. Polyuria and fruity breath odor are associated with ketoacidosis, while blurred vision can occur in both conditions but is not specific enough alone to indicate immediate glucose administration.