ATI LPN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
The nurse leaves a pressure ulcer open to air and does not apply a dressing. Which stage pressure ulcer does this patient have?
Correct Answer: A
Rationale: Stage I ulcers intact, red heal without dressings , per the flashcards, resolving in 7-14 days with relief. Stage II , III , and IV need dressings for deeper damage. Open-to-air suits Stage I, making this the correct stage.
Question 2 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 3 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 4 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.
Question 5 of 5
Which is an example of a nurse practicing culturally congruent care?
Correct Answer: A
Rationale: Culturally congruent care integrates client values with evidence. Using evidence-based practice , per Leininger's theory, adapts care to cultural needs while maintaining efficacy (e.g., respecting herbal use with meds). Nurse-centered beliefs or discouraging healers dismiss culture. Standardized plans lack personalization. This balances science and culture, making it the correct example.