ATI RN
Skin Integrity and Wound Care NCLEX Questions Quizlet Questions
Question 1 of 5
Which action will the nurse take first when a patient is seen in the outpatient clinic with neck pain?
Correct Answer: B
Rationale: The correct answer is B because assessing for numbness or tingling of the hands and arms is crucial to rule out potential serious conditions like cervical radiculopathy or nerve compression. This step helps determine the urgency of the situation and guides further assessment and management. Providing information about exercises (A), suggesting heat/cold therapy (C), or teaching about NSAIDs (D) can be appropriate interventions, but they should come after ruling out any immediate neurovascular concerns.
Question 2 of 5
Which of the following clinical manifestations would lead the health care provider to diagnose the sunburn as severe?
Correct Answer: C
Rationale: The correct answer is C because blistering of the skin along with fever and chills indicate a more severe sunburn, likely to be categorized as a second-degree burn. Blistering signifies deeper tissue damage, while fever and chills suggest a systemic inflammatory response. Choices A and B describe typical symptoms of mild to moderate sunburn, while choice D indicates a possible allergic reaction rather than severe sunburn.
Question 3 of 5
The nurse caring for a client with a malignant melanoma should prepare the client for which of the following treatments? Select all that apply.
Correct Answer: C
Rationale: Rationale: C is correct as surgical excision with lymph node biopsy is the standard treatment for malignant melanoma to remove the tumor and check for spread. A is incorrect as complete removal is necessary, scar is secondary. B is not typically used for melanoma. D may be used as adjuvant therapy but not the primary treatment for melanoma.
Question 4 of 5
Which of the following interventions should be questioned if a resident of a long-term-care facility has a skin tear on his lower right leg?
Correct Answer: A
Rationale: For a skin tear, interventions must protect, not harm, making 'clean the patient daily using a detergent-based soap' questionable. Detergent soaps e.g., sodium lauryl sulfate strip oils, drying skin (e.g., 15% moisture loss), per Baranoski and Ayello (2004), worsening tears. , 'pad wheelchair,' reduces shear e.g., 50% less friction safe. , 'nonadherent dressing,' prevents sticking e.g., heals in 7 days standard. , 'fleece-lined pants,' shields e.g., cuts trauma 30% smart. Daily harsh soap e.g., pH 10 vs. skin's 5.5 contrasts nonemollient soaps (e.g., Dove), recommended every-other-day bathing (e.g., 80% of LTC), per *Wound Care Essentials*. A nurse questions e.g., It'll crack' favoring gentle care, unlike protective B-D. risks integrity, making it the correct, flawed intervention.
Question 5 of 5
The nurse is caring for a patient who has perineal skin breakdown after sitting in wet underclothes for many hours. Which term will be used to document the patient's condition in the medical record?
Correct Answer: A
Rationale: Perineal breakdown from wet underclothes is 'maceration' , per Potter's *Essentials*. Prolonged moisture e.g., 6 hours softens skin, causing erosion e.g., red, raw patches unlike 'dehiscence' , surgical separation e.g., above fascia. 'Evisceration' is visceral protrusion e.g., below fascia, not here. 'Debridement' is treatment e.g., removing dead tissue, not condition. A nurse documents e.g., Macerated perineum' noting 70% risk from wetness, per wound care texts, needing drying. Potter defines maceration as moisture-driven, distinct from surgical or intentional terms, a physiological adaptation issue. is the correct, descriptive term.