ATI RN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
The nurse is assessing a group of older adults. Which client is at greatest risk for skin breakdown? A person who has:
Correct Answer: B
Rationale: Correct Answer: B - Reduced sensation of pressure Rationale: 1. Reduced sensation of pressure leads to decreased ability to feel discomfort and adjust position, increasing risk of prolonged pressure on the skin. 2. Prolonged pressure can cause tissue damage and skin breakdown, especially in older adults with fragile skin. 3. Proper sensation of pressure is crucial for individuals to respond to discomfort and prevent pressure ulcers. Summary of Other Choices: A. Altered balance: While altered balance can increase the risk of falls, it is not directly related to skin breakdown. C. Impaired hearing ability: Impaired hearing may affect communication but does not directly impact skin breakdown. D. Impaired visual acuity: Impaired vision can affect safety and mobility but is not a primary risk factor for skin breakdown.
Question 2 of 5
What initial action should the nurse take when Aaron expresses frustration?
Correct Answer: B
Rationale: The correct initial action for the nurse to take when Aaron expresses frustration is to offer him the opportunity to discuss his feelings of anger and hopelessness (Choice B). This is the best approach because it shows empathy and allows Aaron to express his emotions, which can help in understanding the root cause of his frustration. Confronting him (Choice A) may escalate the situation and worsen his behavior. Involving Aaron's parents (Choice C) without first addressing Aaron's feelings directly may not be effective. Lastly, reassuring him about his future hospital visits (Choice D) does not address the current emotional distress he is experiencing. In summary, Choice B is the most appropriate as it focuses on addressing Aaron's emotions and providing a supportive environment for him to express his frustrations.
Question 3 of 5
The nurse is caring for a client who is being discharged following abdominal surgery with an incision. Which instruction is most important for the nurse to teach this client regarding wound healing?
Correct Answer: D
Rationale: The correct answer is D because it emphasizes the importance of monitoring for signs of infection, such as swelling, warmth, or tenderness, which are crucial in detecting complications early. This instruction ensures prompt medical intervention if needed, promoting proper wound healing. A: Thoroughly irrigating the wound with hydrogen peroxide once a day can be too harsh and may delay healing by damaging healthy tissue. B: Applying a lubricating lotion to the edges of the wound may not address infection risk or proper wound care. C: Adding more fruits and vegetables to the diet is beneficial for overall health but not directly related to wound healing or preventing complications.
Question 4 of 5
Which client should the nurse anticipate will have the greatest psychosocial needs?
Correct Answer: D
Rationale: The correct answer is D because a client in isolation typically has limited social interaction, leading to increased feelings of loneliness, anxiety, and depression. Isolation can have a significant impact on psychosocial well-being. In contrast, clients under standard precautions (Choice A) and droplet precautions (Choice C) can still have regular social interactions. Choice B, a client taking antibiotics, does not directly correlate with increased psychosocial needs. In summary, clients in isolation are more likely to have greater psychosocial needs compared to the other options.
Question 5 of 5
On which region of the body would the nurse most expect to observe erysipelas?
Correct Answer: B
Rationale: The correct answer is B: Ankles. Erysipelas is a bacterial skin infection typically caused by Streptococcus bacteria. The lower extremities, especially the ankles, are common sites for erysipelas due to factors like compromised circulation and skin trauma increasing susceptibility. Erysipelas presents with well-defined, raised, and erythematous patches on the skin, commonly seen on the lower legs and ankles. The infection usually affects the superficial layers of the skin and subcutaneous tissues, leading to characteristic symptoms such as warmth, pain, and swelling in the affected area. Choices A, C, and D are incorrect as erysipelas typically occurs on the lower extremities rather than the abdomen, neck, or back.