ATI LPN
NCLEX Style Questions on Skin Integrity and Wound Care Questions
Question 1 of 5
Which situation makes the nurse suspect the client has glaucoma?
Correct Answer: A
Rationale: Glaucoma causes peripheral vision loss, which could prevent seeing a car in the next lane, leading to an accident, aligning with its typical presentation.
Question 2 of 5
Which laboratory value should be monitored by the nurse for the client diagnosed with diabetes insipidus?
Correct Answer: A
Rationale: Diabetes insipidus causes dilute urine and hypernatremia; serum sodium monitoring is key.
Question 3 of 5
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds?
Correct Answer: B
Rationale: Pulmonary edema from MI causes crackles due to fluid in the alveoli.
Question 4 of 5
A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which finding supports this diagnosis?
Correct Answer: B
Rationale: Because of the profound deficiency of insulin associated with DKA, glucose cannot be used for energy and the body breaks down fat as a secondary source of energy, leading to acidosis and potential coma. While deep, rapid breathing (Kussmaul's respirations) and elevated blood glucose are also signs, the comatose state is a critical indicator of severe untreated DKA.
Question 5 of 5
A client has been diagnosed with hyperthyroidism. The nurse monitors for which sign or symptom indicating a complication of this disorder?
Correct Answer: A
Rationale: Fever can indicate thyroid storm, a life-threatening complication of hyperthyroidism, characterized by hypermetabolism, unlike lethargy or bradycardia, which suggest hypothyroidism.