The nurse is performing a head-to-toe assessment for an older adult. W

Integumentary Disorders NCLEX RN Questions

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Question 1 of 5.

The nurse is performing a head-to-toe assessment for an older adult. Which finding from the integumentary assessment does the nurse recognize as a normal age-related change:

A. Moist skin

B. Increased nail growth

C. Dry, itchy skin

D. Increased skin pigmentation

Explanation: Dry, itchy skin is a normal age-related change due to decreased oil production and skin thinning.

Question 2 of 5.

A nurse is caring for a client at risk of developing pressure ulcers. Which of the following is an intrinsic risk factor that contributes to this increased risk?

A. Shearing

B. Friction

C. Impaired tissue perfusion

D. Pressure

Explanation: Impaired tissue perfusion is an intrinsic risk factor because it originates within the body, affecting blood flow and tissue oxygenation, which can lead to pressure ulcer development. Shearing, friction, and pressure are extrinsic factors as they are external forces acting on the skin.

Question 3 of 5.

The nurse recognizes that rewarming a client with hypothermia must be done slowly to prevent

A. Superficial burns

B. ventricular fibrillation

C. frostbite

D. muscle spasms

Explanation: Rapid rewarming can cause ventricular fibrillation due to sudden changes in core temperature affecting cardiac rhythm. Slow rewarming helps stabilize the cardiovascular system.

Question 4 of 5.

Which of the following interventions by the newly hired nurse requires follow-up? Select all that apply.

A. Applies zinc oxide to the client's perineal skin

B. Provides a donut pillow while the client is sitting in the chair

C. Maintain the head of the client's bed at 90 degrees

D. Encourages the client to consume foods rich in carbohydrates

E. Uses a pillow to float the client's heels

Explanation: Donut pillows can increase pressure on surrounding tissues, worsening ulcer risk. Maintaining the head of the bed at 90 degrees increases shearing forces, promoting ulcer development. Zinc oxide, high-protein diets (not just carbohydrates), and floating heels are appropriate interventions.

Question 5 of 5.

The nurse is conducting a staff in-service on managing an acute burn. The nurse should reinforce the utilization of which formula to guide fluid resuscitation?

A. 4 mL x kg x Total Body Surface Area (TBSA) burned

B. 30 mL/kg

C. 0.5 mL/kg/hr

D. 0.10 mL/kg/hr

Explanation: The Parkland formula (4 mL x kg x TBSA burned) is used to calculate fluid resuscitation needs in burn patients to restore circulating volume.