ATI LPN
Skin Integrity and Wound Care Questions Questions
Question 1 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.
Question 2 of 5
The nurse is caring for a patient who is immobile and wants to decrease the formation of pressure ulcers. Which action will the nurse take first?
Correct Answer: C
Rationale: Prevention starts with assessment. Determining risk factors , per the flashcards, identifies vulnerabilities for tailored care. Fluids and nutrition support later. Turning follows risk ID. This ensures effective planning, making it the correct first action.
Question 3 of 5
A patient at risk for skin impairment is able to sit up in a chair. How long should the nurse schedule the patient to sit in the chair?
Correct Answer: A
Rationale: Sitting over 2 hours risks ischemia on ischial tuberosities. Less than 2 hours at a time , per the flashcards, balances mobility and safety. Total daily limits or 30-minute caps are impractical. Comfort-based ignores objective risk. This standard prevents ulcers, making it the correct duration.
Question 4 of 5
The nurse is caring for a postoperative patient recovering from a medial meniscus repair of the right knee. Which action should the nurse take to assist with pain management?
Correct Answer: D
Rationale: Ice (implied Choice D), per nursing practice, reduces pain and swelling post-knee repair. Options are missing, but vital signs or pulses don't relieve pain directly. This evidence-based action, making it the correct choice.
Question 5 of 5
Which level of the cultural environment is being assessed when the nurse asks a client about family rituals and traditions?
Correct Answer: A
Rationale: Bronfenbrenner's ecological model applies here. The microsystem includes immediate settings like family, where rituals and traditions shape daily life and health beliefs, per nursing cultural assessments. Mesosystem links microsystems (e.g., family-school). Exosystem involves external settings (e.g., parent's workplace). Macrosystem is broad cultural values. Family rituals are microsystem-level, guiding care, making this the correct level.