ATI RN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
What is the most accurate definition of a wound?
Correct Answer: A
Rationale: A disruption in normal skin and tissue integrity' defines a wound. Skin breach e.g., cut impairs e.g., 1 cm unlike 'organ function change' , internal e.g., not skin. 'Nervous tissue injury' is narrow e.g., not all wounds. 'Serious trauma, pain' overstates e.g., minor counts. A nurse defines e.g., Skin break' per 100% wound basis, a physiological fact. The text focuses on integrity, making the correct, precise definition.
Question 2 of 5
A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate?
Correct Answer: C
Rationale: I respect your wish not to look at it right now' is appropriate. Trauma e.g., amputation needs empathy e.g., 80% cope better unlike 'doesn't look bad' , dismissive e.g., invalidates. 'Must look someday' pressures e.g., not now. 'Won't go home' threatens e.g., punitive. A nurse says e.g., Your pace' per psychosocial care, a comfort must. The text supports respect, making the correct, patient-centered response.
Question 3 of 5
The sacral area has remained red for two hours and does not blanch when tested. How will the nurse document this finding?
Correct Answer: D
Rationale: The correct answer is D: Reactive hyperemia. This term refers to the redness that persists after pressure is relieved due to increased blood flow to the area. In this case, the sacral area remaining red for two hours and not blanching indicates reactive hyperemia. A: Excessive pallor is incorrect as pallor refers to paleness, not redness. B: Unusual skin mottling is incorrect as mottling refers to irregular patches of skin discoloration, not persistent redness. C: Dependent sacral rubor is incorrect as rubor refers to redness due to increased blood flow, but it does not explain the persistence of redness and lack of blanching.
Question 4 of 5
Which intervention is important to reduce the effect of the diarrhea on Aaron's skin?
Correct Answer: A
Rationale: Correct Answer: A - Apply a moisture-repellent ointment on intact skin areas. Rationale: 1. Diarrhea can lead to skin breakdown due to moisture and irritation. 2. Moisture-repellent ointment forms a protective barrier on intact skin, preventing further damage. 3. Alcohol-based solutions can be drying and irritating to the skin. 4. Positioning a plastic-lined pad can help with cleanup but does not protect the skin. 5. Applying moist heat to the ear is unrelated to addressing skin issues caused by diarrhea.
Question 5 of 5
The nurse encourages Aaron to select which breakfast items to provide a good source of protein?
Correct Answer: D
Rationale: The correct answer is D, eggs and orange juice. Eggs are an excellent source of high-quality protein. They provide essential amino acids needed for growth and repair of body tissues. Orange juice is a good source of vitamin C, which helps with the absorption of iron from eggs. Whole wheat toast with butter (A) and bagels with cream cheese (B) are higher in carbohydrates and fats, not protein. Oatmeal and a banana (C) are healthy options but do not provide as much protein as eggs.