ATI LPN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3 pressure ulcer who has a Nursing diagnosis of Impaired skin integrity?
Correct Answer: B
Rationale: Stage 3 ulcers take time to heal; showing signs of healing in 2 weeks is realistic.
Question 2 of 5
When discussing stage 3 pressure ulcers with the student nurse, which description would the staff nurse include?
Correct Answer: B
Rationale: Stage 3 ulcers extend into subcutaneous tissue but not through fascia, and may include tunneling.
Question 3 of 5
Which item should the nurse use first to assist in staging an ulcer on the heel of a darkly pigmented skin patient?
Correct Answer: D
Rationale: Staging in darkly pigmented skin requires clear visualization. Natural light , per the flashcards, is the first tool, enhancing inspection by avoiding fluorescent distortion, revealing subtle erythema or discoloration. Measuring tape sizes later. Cotton applicators assess depth post-staging. Gloves ensure sterility but don't aid visibility. Accurate initial assessment, per nursing protocols, hinges on lighting to differentiate stages (e.g., Stage I vs. II), making this the correct first item.
Question 4 of 5
Which nursing observation will indicate the wound healed by secondary intention?
Correct Answer: D
Rationale: Secondary intention, per the flashcards, results in severe scarring as open wounds fill with scar tissue, often impairing function. Options A-C are missing, but minimal scarring or redness don't fit. Nurses observe this in burns or ulcers, noting prolonged healing and infection risk, making this the correct indicator.
Question 5 of 5
The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous with a drain in place. Which statement by the patient indicates issues with self-concept?
Correct Answer: C
Rationale: Self-concept ties to body image. ' I really need a bath, I feel so awful' , per the flashcards, reflects shame over odor, impacting esteem. Weakness is physical. Going home and dinner are neutral. Nurses address this emotional cue, making it the correct statement.