ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
The nurse is caring for a patient with a Stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. Which is the best goal for this patient?
Correct Answer: D
Rationale: Measurable goals suit unconscious patients. Remain free of odorous or purulent drainage' , per the flashcards, indicates no infection. Stating signs isn't possible. Family actions (Choices B, C) are interventions. This reflects prevention, making it the correct goal.
Question 2 of 5
Which action should the nurse take to meet the nutritional needs of a Jewish client?
Correct Answer: B
Rationale: Culturally sensitive care respects individual beliefs. Asking the client about dietary preferences ensures the nurse addresses specific Jewish dietary laws (e.g., kosher), which vary (e.g., avoiding pork or mixing dairy and meat). Ordering a kosher meal assumes uniformity, risking oversight of personal variations. Paper plates are irrelevant to nutrition. Consulting a dietitian is secondary without client input. Per nursing principles, understanding the client's needs first fosters trust and tailors care, aligning with transcultural models like Leininger's, making this the correct action.
Question 3 of 5
The nurse is caring for a client who is reluctant to take pain medication, fearing that if they do so others will see them as weak. Which of the following statements best describes how the nurse should initially respond?
Correct Answer: A
Rationale: Cultural humility starts with understanding. Acknowledging cultural influences and listening , per nursing standards, respects the client's fear of weakness (e.g., stoicism in some cultures) and builds trust. Education or encouragement (Choices C, D) without context may dismiss beliefs, risking resistance. Initial listening informs tailored care, making this the correct response.
Question 4 of 5
A nurse is providing care to an older adult client who follows a traditional cultural practice of using herbal remedies alongside prescribed medications. How can the nurse incorporate the client's cultural practice of using herbal remedies into the plan of care while ensuring the client's safety and well-being?
Correct Answer: C
Rationale: Safety and culture balance via collaboration. Assessing safety and interactions , per nursing standards, integrates herbal use (e.g., checking for drug-herb conflicts like St. John's Wort) with medical care. Education to stop dismisses beliefs. Herbalist referral shifts responsibility. Disregarding lacks respect. This ensures holistic care, making it the correct action.
Question 5 of 5
A client from an Asian background prefers a holistic approach to health care and believes that physical and mental health are interconnected. According to the Giger and Davidhizar model, which component of the model should the nurse consider when providing care for the client?
Correct Answer: C
Rationale: Giger and Davidhizar's model includes six phenomena. Communication is key for a holistic Asian client, as beliefs about health interconnection (e.g., yin-yang balance) are expressed verbally/nonverbally, guiding care. Biological variation addresses physiology. Social organization is family structure. Time is orientation. Nurses adapt via communication, making it the correct component.