ATI RN
NCLEX Questions Skin Integrity and Wound Care Questions
Question 1 of 5
When performing a skin assessment, the nurse notes angiomas on the chest of an older patient. Which action should the nurse take next?
Correct Answer: B
Rationale: The correct answer is B because angiomas on the chest can be a sign of liver disease. The nurse should assess the patient for other signs of liver disease, such as jaundice or abdominal distension. This can help in early detection and management of liver issues. Choice A is incorrect as referring to a dermatologist would not address the underlying cause of the angiomas. Choice C is incorrect as it does not address the potential health concern indicated by the angiomas. Choice D is incorrect as it does not address the specific issue of liver disease associated with angiomas.
Question 2 of 5
Which information will the nurse include when teaching an older patient about skin care?
Correct Answer: C
Rationale: The correct answer is C: Use warm water and a moisturizing soap when bathing. This is because warm water helps maintain skin hydration and a moisturizing soap prevents dryness, which is crucial for older adults with naturally drier skin. Washing with soap daily (option B) can strip the skin of its natural oils, leading to further dryness. Option A is incorrect because drying the skin thoroughly can exacerbate dryness. Option D is incorrect as antibacterial soaps can be harsh and drying, and unnecessary for routine skin care.
Question 3 of 5
A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D because asking the patient to describe the impact of psoriasis on quality of life is the first step in understanding the patient's perspective and needs. This allows the nurse to assess the severity of the emotional and social impact, which can guide further interventions. Options A, B, and C do not address the root cause of the patient's social withdrawal and may not be as effective in addressing the patient's emotional distress.
Question 4 of 5
The nurse finds that a patient can flex the arms when no resistance is applied but is unable to flex when the nurse applies light resistance. The nurse should document the patient’s muscle strength as level
Correct Answer: C
Rationale: The correct answer is C (2). This patient demonstrates muscle strength that is graded as 2 according to the Medical Research Council (MRC) scale. A score of 2 indicates that the patient can move the joint against gravity but not against resistance. Choices A, B, and D are incorrect because they represent different levels of muscle strength based on the MRC scale. Choice A (0) indicates no muscle contraction, choice B (1) indicates a flicker or trace of contraction, and choice D (3) indicates movement against gravity but not against resistance. Therefore, the best description of the patient's muscle strength in this scenario is level 2.
Question 5 of 5
Which information will the nurse teach seniors at a community recreation center about ways to prevent fractures?
Correct Answer: C
Rationale: The correct answer is C: Buy shoes that provide good support and are comfortable to wear. This is crucial in preventing falls and fractures as proper footwear can improve balance and reduce the risk of slipping. Seniors should choose shoes with non-slip soles, good arch support, and a comfortable fit to prevent falls. Tacking down scatter rugs (A) can also help prevent falls, but focusing on footwear is more directly related to fracture prevention. Expecting most falls to happen outside the home (B) is not a proactive prevention strategy. Getting instruction in range-of-motion exercises (D) is important for overall mobility but does not directly address fracture prevention.