NCLEX-PN
Integumentary NCLEX Questions Questions
Extract:
Question 1 of 5
When assessing a burn victim's skin the nurse notices the entire right and left upper extremities are red, moist, weeping, and blistered. How should the nurse document the degree and total body surface area (TBSA) burned?
Correct Answer: B
Rationale: Partial-thickness burns damage the dermis and epidermis, often resulting in loss of epidermis and/or blistering. Each entire upper extremity is blistered. Approximately 18% of the TBSA has a partial-thickness burn (9% TBSA per each upper extremity). This is not a first-degree burn—In a first-degree burn the skin may appear red but intact, no weeping, and no blistering. With full-thickness burns there would be loss of tissue and a black or white charred/waxy appearance to the remaining tissues.
Question 2 of 5
The nurse is most accurate in stating that the cause of Meniere's disease is unknown but that the symptoms are related to which disorder?
Correct Answer: B
Rationale: Meniere's symptoms stem from inner ear fluid imbalance.
Question 3 of 5
The nurse is caring for a client who has developed stage IV pressure ulcers on the left trochanter and coccyx. Which collaborative problem has the highest priority?
Correct Answer: B
Rationale: Altered nutrition is critical in stage IV ulcers to support wound healing. Cognition, self-care, and coping are secondary in advanced wounds.
Question 4 of 5
The client is complaining of burning, stabbing pain that radiates around the left rib cage area. The nurse cannot find any type of skin abnormality. Which action should the nurse implement?
Correct Answer: D
Rationale: Burning pain along dermatomes without visible lesions suggests early herpes zoster, linked to prior chickenpox. Cardiac work-up, dismissal, or analgesics are premature.
Question 5 of 5
If the physician wants to check the client's intraocular pressure (IOP), which instrument should the nurse have available?
Correct Answer: B
Rationale: A tonometer measures intraocular pressure, essential for glaucoma assessment.