ATI LPN
Integumentary System Multiple Choice Questions and Answers Questions
Question 1 of 5
Which intervention is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) when caring for the female client experiencing acute pain?
Correct Answer: B
Rationale: The correct answer is B. Applying an ice pack is a non-invasive intervention that can help alleviate acute pain. It does not require specialized medical knowledge and can be safely delegated to the UAP. Here's the rationale: 1) Ice pack application is a basic skill that falls within the scope of practice for UAPs. 2) Ice packs can help reduce inflammation and numb the area, providing pain relief. 3) It is a simple and low-risk intervention that does not require clinical judgment. Choices A, C, and D involve handling medications and assessing pain management, which are beyond the UAP's scope of practice and require nursing expertise.
Question 2 of 5
The elderly client is complaining of abdominal discomfort. Which scientific rationale should the nurse remember when addressing an elderly client's perception of pain?
Correct Answer: C
Rationale: The correct answer is C because as people age, their reaction to painful stimuli may decrease due to changes in the nervous system. This is important for nurses to consider when assessing and managing pain in elderly clients. Choice A is incorrect as elderly clients may have different pain perceptions compared to other age groups. Choice B is incorrect as not all elderly clients require more pain medication. Choice D is incorrect as the Wong scale is not specifically recommended for elderly clients.
Question 3 of 5
The nurse is admitting a client diagnosed with primary adrenal cortex insufficiency (Addison's disease). Which clinical manifestations should the nurse expect to assess?
Correct Answer: C
Rationale: The correct answer is C: Bronze pigmentation, hypotension, and anorexia. Primary adrenal cortex insufficiency (Addison's disease) is characterized by decreased production of cortisol and aldosterone. Bronze pigmentation is due to increased melanocyte-stimulating hormone. Hypotension is a result of aldosterone deficiency leading to sodium and water loss. Anorexia can occur due to decreased cortisol levels affecting glucose metabolism. A: Moon face, buffalo hump, and hyperglycemia are manifestations of Cushing's syndrome, which is excessive cortisol production. B: Hirsutism, fever, and irritability are not typical manifestations of Addison's disease. D: Tachycardia, bulging eyes, and goiter are signs of hyperthyroidism, not adrenal insufficiency.
Question 4 of 5
The client is one (1) hour postoperative thyroidectomy. Which intervention should the nurse implement?
Correct Answer: A
Rationale: The correct answer is A: Check the posterior neck for bleeding. This intervention is crucial post-thyroidectomy to monitor for any signs of bleeding, which can be life-threatening. Checking for bleeding is a priority as it can lead to airway compromise and requires immediate intervention. Assessing for Chvostek's sign (B) is unrelated to a thyroidectomy and is used to detect hypocalcemia. Monitoring serum calcium level (C) is important but not as immediate as checking for bleeding. Changing the surgical dressing (D) is important for wound care but does not address the critical need to assess for bleeding.
Question 5 of 5
The client has developed atrial fibrillation, with a ventricular rate of 150 beats/minute. The nurse should assess the client for which associated signs and/or symptoms?
Correct Answer: C
Rationale: The correct answer is C: Hypotension and dizziness. In atrial fibrillation with a rapid ventricular rate, the heart is unable to effectively pump blood, leading to decreased cardiac output. This can result in hypotension and dizziness due to inadequate perfusion of tissues. Flat neck veins (choice A) are not typically associated with atrial fibrillation. Nausea and vomiting (choice B) may occur in some cases but are not the primary signs and symptoms. Hypertension and headache (choice D) are less likely to occur with atrial fibrillation and a rapid ventricular rate.