ATI LPN
Fundamentals of Nursing Skin Integrity Questions Questions
Question 1 of 9
The nurse administered morphine sulfate, a narcotic analgesic, IVP 45 minutes ago to a client diagnosed with herpes zoster. On reassessment, the client complains the pain is at a '5' on a 1-to-10 scale. Which intervention should the nurse implement?
Correct Answer: C
Rationale: Persistent pain at level 5 post-morphine indicates inadequate control, necessitating HCP notification for adjustment.
Question 2 of 9
Which statement indicates acceptance of a right above-the-elbow amputation?
Correct Answer: B
Rationale: Acceptance involves engaging in rehabilitation and future planning.
Question 3 of 9
The client diagnosed with psoriasis who is being treated with a tar preparation reports an odor and staining. Which intervention should the nurse implement?
Correct Answer: B
Rationale: Tar preparations for psoriasis are effective but cause odor and staining, which are expected. Clinic visits, discontinuation, or bleach aren't warranted.
Question 4 of 9
A patient admitted with severe burns to his face and hands is showing signs of extreme agitation. The nurse should explore the mechanism of burn injury possibly related to:
Correct Answer: B
Rationale: A vague or inconsistent injury history, burns to the face and hands, and signs of agitation or substance withdrawal should alert the nurse to a potential methamphetamine-related injury.
Question 5 of 9
How should the nurse document the finding of small, reddish purple nonraised lesions that do not fade or blanch with pressure on an older adult client?
Correct Answer: A
Rationale: Petechiae are small, reddish purple nonraised lesions that do not fade or blanch with pressure. Ecchymoses are larger areas of hemorrhaging, commonly known as bruising.
Question 6 of 9
The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patients ankle. How should the nurse determine if the lesion is related to intradermal bleeding?
Correct Answer: B
Rationale: If the lesion is caused by intradermal or subcutaneous bleeding or a nonvascular cause, the discoloration will remain when direct pressure is applied to the lesion. If the lesion is caused by blood vessel dilation, blanching will occur with direct pressure. The other assessments will assess circulation to the leg, but will not be helpful in determining the etiology of the lesion.
Question 7 of 9
The nurse is caring for a patient with a major burn on the right arm. Which function of the skin is most affected by this injury?
Correct Answer: C
Rationale: The skin's protective barrier is compromised in burns, making protection the most affected function.
Question 8 of 9
Two weeks after a severe burn of over 20% of the body, the patient vomits bright red blood. Which condition is most likely?
Correct Answer: A
Rationale: Curling ulcer is a duodenal ulcer that develops 8 to 14 days after severe burns on the surface of the body. The first sign is usually vomiting of bright red blood.
Question 9 of 9
The nurse administered morphine sulfate, a narcotic analgesic, IVP 45 minutes ago to a client diagnosed with herpes zoster. On reassessment, the client complains the pain is at a '5' on a 1-to-10 scale. Which intervention should the nurse implement?
Correct Answer: C
Rationale: Persistent pain at level 5 post-morphine indicates inadequate control, necessitating HCP notification for adjustment.