ATI LPN
Integumentary System Exam Questions Questions
Question 1 of 5
When examining an 87-year-old home health patient, the nurse notes a musky, sour body odor. Based on this assessment, the most appropriate nursing action is to
Correct Answer: A
Rationale: The correct answer is A because the musky, sour body odor observed in the 87-year-old patient likely indicates poor personal hygiene. Therefore, scheduling a nursing assistant to help the patient bathe several times weekly is the most appropriate action to address this issue and promote cleanliness and comfort. This approach ensures proper hygiene practices are maintained, which can help improve the patient's overall well-being and prevent skin infections. Choices B, C, and D are incorrect because teaching the patient to apply moisturizing lotion, obtaining a prescription for a topical antifungal, or asking about skin medications do not directly address the root cause of the musky odor, which is likely due to poor hygiene. These options focus on skincare and treatment for skin conditions, which may not be the primary concern in this case.
Question 2 of 5
Assessment of a patients leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion?
Correct Answer: B
Rationale: The correct answer is B: Ulcer. An ulcer is a skin lesion characterized by the loss of skin tissue, resulting in an open sore. In this case, the presence of necrotic tissue deeper than the epidermis indicates tissue loss, consistent with an ulcer. A keloid is a raised scar, not an open sore like an ulcer. A fissure is a linear crack in the skin, different from a circular area of tissue loss. An erosion is a superficial loss of skin layers, not as deep as what is described in the scenario. Therefore, the presence of necrotic tissue deeper than the epidermis points towards an ulcer as the correct skin lesion.
Question 3 of 5
Patients with burns may have mesh grafts or sheet grafts. Which of the following sites is most likely to have a sheet graft applied?
Correct Answer: B
Rationale: The correct answer is B: Face. Sheet grafts are typically used on areas where a smooth, even surface is desired, such as the face. Mesh grafts, on the other hand, are often used on areas that need more flexibility and conformity, like the arms and legs. Chest may also require mesh grafts due to its irregular shape. So, face is the most likely site for a sheet graft due to the need for aesthetic outcomes and minimal scarring.
Question 4 of 5
While changing the dressing on a burned arm the patient complains of feeling cold and having extreme pain. However, the patient asks the nurse to not apply so much pressure when wrapping gauze around the limb. What should these findings indicate to the nurse?
Correct Answer: C
Rationale: The correct answer is C: Encapsulated nerve endings in the arm are intact. This is indicated by the fact that the patient is experiencing extreme pain (associated with free nerve endings) but can still differentiate pressure sensation (associated with encapsulated nerve endings). If all nerves were damaged (Choice A), the patient would not feel any sensation. If free nerve endings were injured (Choice B), the patient would not feel pain. If encapsulated nerve endings were injured (Choice D), the patient would not be able to differentiate pressure sensation.
Question 5 of 5
A nurse is caring for a patient who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. Which of the following measures will best achieve these goals?
Correct Answer: A
Rationale: The correct answer is A: Encouraging the patient to turn from side to side and to assume a prone position. This measure is essential for preventing hip flexion contractures after a below-the-knee amputation. Turning from side to side and assuming a prone position help in maintaining proper positioning and preventing hip flexion contractures by stretching the hip extensors and preventing the hip from being in a prolonged flexed position. Choice B is incorrect because initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation may be too late to prevent contractures. Choice C is incorrect as minimizing movement of the flexor muscles of the hip can actually lead to contractures. Choice D is also incorrect as sitting in a chair for extended periods can promote hip flexion contractures.