ATI LPN
Integumentary System Exam Questions Questions
Question 1 of 5
Which nursing intervention is the highest priority when administering pain medication to a client experiencing acute pain?
Correct Answer: C
Rationale: The correct answer is C: Check for the client's allergies. This is the highest priority because knowing the client's allergies helps prevent potential adverse reactions when administering pain medication. Monitoring vital signs (A) is important but comes after checking for allergies. Verifying the time of the last dose (B) is essential for dose timing but not the highest priority. Discussing pain with the client (D) is important for assessment but not as critical as ensuring safety by checking for allergies.
Question 2 of 5
The nurse is assessing the client's cranial nerves. Which assessment data indicate cranial nerve I is intact?
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct: 1. Cranial nerve I is the olfactory nerve responsible for the sense of smell. 2. Assessing the client's ability to identify a peppermint smell tests the olfactory nerve. 3. If the client can identify the smell, it indicates cranial nerve I is intact. Summary: A: Assessing cold and hot sensation on the face tests cranial nerve V (trigeminal nerve). B: Tongue tremor is not related to cranial nerve I, but to cranial nerve XII (hypoglossal nerve). C: Ptosis of the eyelids is related to cranial nerve III (oculomotor nerve), not cranial nerve I.
Question 3 of 5
The nurse caring for a client diagnosed with cancer of the pancreas writes the nursing diagnosis of 'risk for altered skin integrity related to pruritus.' Which intervention should the nurse implement?
Correct Answer: D
Rationale: The correct answer is D: Have the client keep the fingernails short. Pancreatic cancer can cause pruritus (itching), and keeping fingernails short can prevent skin damage from scratching. Assessing tissue turgor (A) is unrelated to pruritus. Applying antifungal creams (B) is not indicated unless there is a fungal infection. Monitoring bony prominences for breakdown (C) is more relevant to preventing pressure ulcers. Keeping fingernails short helps prevent skin damage and is the most appropriate intervention for addressing pruritus in this case.
Question 4 of 5
Which client history is most significant in the development of symptoms for a client who has iatrogenic Cushing's disease?
Correct Answer: C
Rationale: The correct answer is C: History of long-term glucocorticoid use. Glucocorticoids are known to cause iatrogenic Cushing's disease. This choice directly correlates with the condition's development. Other choices like A (anabolic steroids) and B (inhaled steroids for asthma) are not typically associated with iatrogenic Cushing's. Choice D (family history of increased cortisol production) is not a direct cause of iatrogenic Cushing's, as it is not related to external factors like medication use.
Question 5 of 5
A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item?
Correct Answer: C
Rationale: The correct answer is C: Blood pressure and oxygen saturation. Assessing blood pressure and oxygen saturation is crucial in a client experiencing frequent premature ventricular contractions to monitor for signs of hemodynamic instability and hypoxia. This assessment helps determine the client's cardiovascular status and oxygenation levels, which are essential in managing and preventing complications associated with arrhythmias. Sensation of palpitations (A) is important, but assessing vital signs takes precedence. Causative factors like caffeine (B) and precipitating factors such as infection (D) are relevant but should be addressed after ensuring the client's immediate physiological needs are met.