ATI RN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
The nurse is admitting a client to the intensive care unit. Earlier, the client presented to the emergency department in early septic shock. Given this information, which assessment findings should the nurse anticipate? Select all that apply.
Correct Answer: B
Rationale: The correct answer is B: Rapid and deep respirations. In early septic shock, the body compensates by increasing the respiratory rate to improve oxygenation. Rapid and deep respirations help maintain oxygen levels. A: Normal blood pressure is not expected in septic shock, as blood pressure tends to drop due to vasodilation. C: Shallow respirations are unlikely as the body usually tries to compensate for decreased oxygen perfusion by increasing the depth of respirations. D: Warm and flushed skin is not typical in septic shock, as the body's response to vasodilation is often cool, clammy skin.
Question 2 of 5
The nurse has provided teaching on multidrug treatment to a client with tuberculosis. Which statement by the client indicates that the teaching was effective?
Correct Answer: D
Rationale: The correct answer is D because it demonstrates an understanding of the rationale behind using multiple drugs to treat tuberculosis, which is to prevent the development of drug resistance. Option A is incorrect because the purpose of multidrug treatment is not to develop immunity. Option B is incorrect as the source of infection does not determine the need for multiple drugs. Option C is incorrect as the duration of treatment is not solely based on contagiousness, but rather on preventing drug resistance.
Question 3 of 5
A 35-yr-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be most important for the nurse to obtain?
Correct Answer: B
Rationale: The correct answer is B. The method of contraception used by the patient is crucial because fluorouracil is a teratogenic medication, meaning it can cause birth defects. Therefore, it is essential to determine the patient's contraceptive method to ensure she is not at risk of becoming pregnant while using this medication. Choice A (History of sun exposure) may be relevant but not as critical as ensuring the patient is using proper contraception. Choice C (Length of time using fluorouracil) is important but does not address immediate safety concerns. Choice D (Appearance of treated areas) is important for monitoring treatment progress but does not impact the patient's safety like contraception does.
Question 4 of 5
A patient reports chronic itching of the ankles and continuously scratches the area. Which assessment finding will the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Thickening of the skin around the ankles. Chronic scratching due to itching can lead to lichenification, which is thickening and hardening of the skin. This is a common skin finding in individuals who continuously scratch the affected area. Hypertrophied scars (choice A) are more likely to occur with trauma or injury, not chronic itching. Yellowish-brown skin (choice C) may indicate underlying conditions like jaundice, not necessarily related to chronic itching. Complete absence of melanin (choice D) is not a typical finding related to chronic itching. Therefore, the correct assessment finding would be thickening of the skin around the ankles due to chronic scratching.
Question 5 of 5
The nurse notes the presence of white lesions that resemble milk curds in the back of a patient’s throat. Which question by the nurse is appropriate at this time?
Correct Answer: A
Rationale: The correct answer is A: Are you taking any medications? This question is appropriate because white lesions resembling milk curds in the throat could indicate oral thrush, a fungal infection common in individuals on certain medications like antibiotics or corticosteroids. Asking about medications can help identify the underlying cause. Summary of other choices: B: Do you have a productive cough? - This question is not directly related to the presence of white lesions in the throat. C: How often do you brush your teeth? - Oral hygiene practices are important, but not likely the cause of white lesions. D: Have you had an oral herpes infection? - Oral herpes typically presents as cold sores, not white lesions resembling milk curds in the throat.