NCLEX-PN
Integumentary NCLEX Questions Questions
Extract:
Question 1 of 5
The home health nurse is visiting an elderly client who shows the nurse an area of rough skin with a greasy feel and multiple papules. Which information should the nurse provide the client?
Correct Answer: C
Rationale: Rough, greasy papules may indicate seborrheic keratosis, requiring HCP evaluation at the next visit. Immediate visits, dismissing as normal, or OTC wart removers are inappropriate.
Question 2 of 5
The nurse is irrigating the arm of the client with an acid burn. Which factors should prompt the nurse to continue with the irrigation? Select all that apply.
Correct Answer: A,B,E
Rationale: The presence of a burning sensation may indicate that some acid remains on the skin and additional irrigation is needed. The presence of pain, even though reduced, could indicate that not all of the acid has been removed from the skin. A pH of 4.8 is acidic and indicates there is still acid residue that needs to be removed. A pH of 7 indicates a nonacidic status, which would be a positive finding. The absence of pain would indicate that all acid was removed before it could damage the skin.
Question 3 of 5
The client receives treatment for uncomplicated lower-extremity cellulitis. The nurse notes improvement in the client's condition when which observation is noted on assessment?
Correct Answer: A
Rationale: Cellulitis is an infection with diffuse inflammation occurring in the tissue just under the skin. Observing a decrease in swelling is evidence of improvement. Circulation is not involved with cellulitis, so pedal pulses are unaffected. Increased erythema indicates worsening. A WBC of 14,000/mm3 is elevated, indicating infection.
Question 4 of 5
On the basis of the nurse's understanding of the etiology of pressure ulcers, the nurse should plan for which intervention to promote the client's skin integrity?
Correct Answer: D
Rationale: Repositioning relieves pressure, preventing ulcer progression.
Question 5 of 5
The client is admitted to the outpatient surgery center for removal of a malignant melanoma. Which assessment data indicate the lesion is a malignant melanoma?
Correct Answer: A
Rationale: Asymmetry and irregular borders (ABCD criteria) characterize malignant melanoma. Waxy, scaly, or post-injury lesions suggest other conditions.