ATI RN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
The nurse is caring for a patient who is experiencing a full-thickness repair. Which type of tissue will the nurse expect to observe when the wound is healing?
Correct Answer: C
Rationale: In full-thickness repair, 'granulation' is expected. Red, moist tissue e.g., new vessels marks healing e.g., 2 weeks in unlike 'eschar' , black necrosis e.g., to remove. 'Slough' is yellow, dead e.g., blocks healing. 'Purulent drainage' signals infection e.g., delays. A nurse sees e.g., Pink, budding' per 70% of repairs, a physiological sign. The text ties granulation to progress, making the correct, healing tissue.
Question 2 of 5
The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient?
Correct Answer: C
Rationale: The Braden score is '20'. Subscales: sensory (3, slight impairment), moisture (4, rarely moist), activity (3, walks occasionally), mobility (3, slightly limited), nutrition (4, excellent), friction/shear (4, no problem) total 20. '15' is high risk e.g., <16. '17' undercounts e.g., misses points. '23' is perfect e.g., not here. A nurse tallies e.g., 20, low risk' per 6-23 range, a physiological tool. The text matches this, making the correct, calculated score.
Question 3 of 5
The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial actions should the nurse take to decrease this risk?
Correct Answer: A
Rationale: Use gentle cleansers, and thoroughly dry the skin' is the initial action. Nonionic surfactants e.g., pH 5.5 prevent breakdown e.g., 50% less risk unlike 'therapeutic bed' , secondary e.g., later cost. 'Absorbent pads' are last-resort e.g., controversial. 'Moisture-holding products' harm e.g., maceration. A nurse cleans e.g., Dry post-wash' per basic care, a physiological priority. The text starts with skin hygiene, making the correct, first step.
Question 4 of 5
Which layer of the epidermis contains melanocytes?
Correct Answer: A
Rationale: The stratum basale contains melanocytes, per the ProProfs quiz. As the deepest epidermal layer e.g., 0.05 mm thick it's where melanin production begins e.g., 10% of cells are melanocytes protecting against UV e.g., 90% absorption. 'Stratum lucidum' is a clear layer e.g., palms lacking melanocytes. 'Stratum spinosum' has maturing cells e.g., no pigment role. 'Stratum corneum' is dead cells e.g., outer 0.02 mm no activity. A dermatologist notes e.g., Basale's dark base' per its mitotic and pigment role, a physiological must. The quiz explains its UV shield, making the correct, melanocyte-rich layer.
Question 5 of 5
Which layer of the skin contains cells that are undergoing mitosis?
Correct Answer: D
Rationale: Stratum basale' has mitotic cells, per ProProfs. The deepest layer e.g., 0.05 mm it renews skin e.g., 10 cells/day unlike 'granulosum' , dying e.g., granules. 'Corneum' is dead e.g., outer 0.02 mm. 'Spinosum' matures e.g., less division. A scientist tracks e.g., Basale birth' per 28-day cycle, a physiological must. The quiz links mitosis to basale, making the correct, dividing layer.