ATI LPN
NCLEX Skin Integrity Questions Questions
Question 1 of 5
While assessing a dark-skinned patient at the clinic, the nurse notes the presence of patchy, milky white spots. The nurse knows that this finding is characteristic of what diagnosis?
Correct Answer: D
Rationale: With cyanosis, nail beds are dusky. With polycythemia, the nurse notes ruddy blue face, oral mucosa, and conjunctiva. A bronzed appearance, or external tan, is associated with Addison's disease. Vitiligo is a condition characterized by destruction of the melanocytes in circumscribed areas of skin and appears in light or dark skin as patchy, milky white spots, often symmetric bilaterally.
Question 2 of 5
The nurse is providing care to manage the pain of a patient with burns. The physician has ordered opiates to be given intramuscularly. The nurse contacts the physician to change the order to intravenous administration because:
Correct Answer: D
Rationale: Edema and impaired circulation of the soft tissue interfere with absorption of medications administered subcutaneously or intramuscularly. Even though it is true intramuscular injections disrupt tissue, medication absorption is not effective. Burn pain is severe and intravenous administration is desired to relieve pain, but this is not the physiological basis for giving medications intravenously. Hypermetabolism affects medication effectiveness but is not the rationale for administering opioids intravenously.
Question 3 of 5
The nurse is preparing wet dressings for a patient who has a weeping skin lesion. What is the maximum length of time the wet dressings should be used?
Correct Answer: D
Rationale: Wet dressings should not be prescribed for more than 72 hours, because the skin may become too dry or macerated. Wet dressing can be applied for up to 48 hours.
Question 4 of 5
A nurse's assessment of a patient's knee reveals edema, tenderness, muscle spasms, and ecchymosis. The patient states that 2 days ago he ran 10 miles and now it really hurts to stand up. The nurse should plan care based on the belief that the patient has experienced what?
Correct Answer: B
Rationale: A second-degree strain involves tearing of muscle fibers and is manifested by notable loss of load-bearing strength with accompanying edema, tenderness, muscle spasm, and ecchymosis. A first-degree strain reflects tearing of a few muscle fibers and is accompanied by minor edema, tenderness, and mild muscle spasm, without noticeable loss of function. However, this patient states a loss of function. A sprain normally involves twisting, which is inconsistent with the patient's overuse injury.
Question 5 of 5
A patient has presented to the emergency department with an injury to the wrist. The patient is diagnosed with a third-degree strain. Why would the physician order an x-ray of the wrist?
Correct Answer: C
Rationale: An x-ray should be obtained to rule out bone injury, because an avulsion fracture (in which a bone fragment is pulled away from the bone by a tendon) may be associated with a third-degree strain. Nerve damage, compartment syndrome, and greenstick fractures are not associated with third-degree strains.