ACTUAL EXAM TEST BANK 200
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED
A nurse is assessing a client at risk for impaired skin integrity. Which factors increase this risk?
Correct Answer:
Impaired mobility, poor nutrition, dehydration, and tissue trauma
Expert Rationale:
Impaired tissue integrity is commonly caused by reduced perfusion, inadequate nutrition,
immobility, moisture imbalance, and exposure to irritants or trauma. These factors compromise
skin structure and healing ability.
Why other options are incorrect:
• Adequate hydration: Protects skin integrity.
• Frequent repositioning: Prevents breakdown.
• Balanced nutrition: Supports tissue repair.
DIF: Analysis
REF: Skin Integrity
OBJ: Identify risk factors
TOP: Nursing Assessment
A client presents with leg pain during walking that resolves with rest, shiny hairless skin, and
diminished pedal pulses. What is the most likely condition?
Correct Answer:
Peripheral artery disease (PAD)
Expert Rationale:
PAD is caused by atherosclerosis leading to decreased arterial blood flow. Classic signs include
intermittent claudication, hair loss, shiny skin, weak pulses, and pallor with elevation.
,Why other options are incorrect:
• Venous insufficiency: Causes edema and weeping wounds.
• DVT: Causes acute swelling and pain.
• Neuropathy: Does not affect pulses.
DIF: Analysis
REF: Vascular Disorders
OBJ: Identify PAD
TOP: Pathophysiology
A client with peripheral artery disease asks how to manage symptoms. Which instruction is
most appropriate?
Correct Answer:
Keep legs in a dependent position
Expert Rationale:
Keeping the legs dependent promotes arterial blood flow in PAD. Elevation and compression
can further reduce perfusion and should be avoided.
Why other options are incorrect:
• Elevate legs: Reduces arterial flow.
• Apply compression stockings: Contraindicated in PAD.
• Limit movement: Exercise improves circulation.
DIF: Application
REF: PAD Interventions
OBJ: Promote circulation
TOP: Nursing Care
A wound is noted on the tip of a client’s toe. It appears round, “punched out,” with minimal
drainage and black eschar. What type of ulcer is this?
Correct Answer:
Arterial ulcer
Expert Rationale:
Arterial ulcers occur due to poor perfusion and are typically found on toes or lateral malleolus.
They appear well-defined, deep, and may have black eschar due to tissue necrosis.
Why other options are incorrect:
,• Venous ulcer: Irregular shape with heavy drainage.
• Pressure injury: Occurs over bony prominences.
• Diabetic ulcer: Often on plantar surface.
DIF: Analysis
REF: Wound Types
OBJ: Differentiate ulcers
TOP: Assessment
A client presents with lower leg edema, brown discoloration, and a weeping wound near the
medial malleolus. What is the most likely diagnosis?
Correct Answer:
Chronic venous insufficiency
Expert Rationale:
Venous insufficiency results from valve failure, leading to blood pooling. Symptoms include
edema, hemosiderin staining, and irregular draining ulcers near the medial malleolus.
Why other options are incorrect:
• PAD: Presents with dry, pale skin.
• Cellulitis: Acute infection signs.
• DVT: Acute swelling without skin discoloration pattern.
DIF: Analysis
REF: Venous Disorders
OBJ: Identify venous insufficiency
TOP: Pathophysiology
A client is at risk for pressure injuries. Which intervention is most effective for prevention?
Correct Answer:
Reposition the client every 2 hours
Expert Rationale:
Frequent repositioning reduces prolonged pressure on tissues, improving circulation and
preventing ischemia that leads to pressure injuries.
Why other options are incorrect:
• Limiting movement: Increases risk.
• Moist skin: Increases breakdown risk.
• Low-protein diet: Impairs healing.
, DIF: Application
REF: Pressure Injury Prevention
OBJ: Prevent skin breakdown
TOP: Nursing Care
A client has full-thickness skin loss with visible bone. What stage pressure injury is this?
Correct Answer:
Stage 4
Expert Rationale:
Stage 4 pressure injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle,
indicating severe damage.
Why other options are incorrect:
• Stage 1: Intact skin only.
• Stage 2: Partial thickness.
• Stage 3: No exposed bone.
DIF: Knowledge
REF: Pressure Injuries
OBJ: Classify wounds
TOP: Assessment
A client with left-sided heart failure presents with shortness of breath and crackles. What is the
underlying cause?
Correct Answer:
Blood backing up into the pulmonary circulation
Expert Rationale:
Left-sided heart failure causes blood to back up into the lungs, leading to pulmonary edema,
dyspnea, orthopnea, and crackles.
Why other options are incorrect:
• Systemic venous congestion: Right-sided failure.
• Kidney failure: Not primary cause.
• Liver congestion: Right-sided failure.
DIF: Analysis
REF: Heart Failure
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED
A nurse is assessing a client at risk for impaired skin integrity. Which factors increase this risk?
Correct Answer:
Impaired mobility, poor nutrition, dehydration, and tissue trauma
Expert Rationale:
Impaired tissue integrity is commonly caused by reduced perfusion, inadequate nutrition,
immobility, moisture imbalance, and exposure to irritants or trauma. These factors compromise
skin structure and healing ability.
Why other options are incorrect:
• Adequate hydration: Protects skin integrity.
• Frequent repositioning: Prevents breakdown.
• Balanced nutrition: Supports tissue repair.
DIF: Analysis
REF: Skin Integrity
OBJ: Identify risk factors
TOP: Nursing Assessment
A client presents with leg pain during walking that resolves with rest, shiny hairless skin, and
diminished pedal pulses. What is the most likely condition?
Correct Answer:
Peripheral artery disease (PAD)
Expert Rationale:
PAD is caused by atherosclerosis leading to decreased arterial blood flow. Classic signs include
intermittent claudication, hair loss, shiny skin, weak pulses, and pallor with elevation.
,Why other options are incorrect:
• Venous insufficiency: Causes edema and weeping wounds.
• DVT: Causes acute swelling and pain.
• Neuropathy: Does not affect pulses.
DIF: Analysis
REF: Vascular Disorders
OBJ: Identify PAD
TOP: Pathophysiology
A client with peripheral artery disease asks how to manage symptoms. Which instruction is
most appropriate?
Correct Answer:
Keep legs in a dependent position
Expert Rationale:
Keeping the legs dependent promotes arterial blood flow in PAD. Elevation and compression
can further reduce perfusion and should be avoided.
Why other options are incorrect:
• Elevate legs: Reduces arterial flow.
• Apply compression stockings: Contraindicated in PAD.
• Limit movement: Exercise improves circulation.
DIF: Application
REF: PAD Interventions
OBJ: Promote circulation
TOP: Nursing Care
A wound is noted on the tip of a client’s toe. It appears round, “punched out,” with minimal
drainage and black eschar. What type of ulcer is this?
Correct Answer:
Arterial ulcer
Expert Rationale:
Arterial ulcers occur due to poor perfusion and are typically found on toes or lateral malleolus.
They appear well-defined, deep, and may have black eschar due to tissue necrosis.
Why other options are incorrect:
,• Venous ulcer: Irregular shape with heavy drainage.
• Pressure injury: Occurs over bony prominences.
• Diabetic ulcer: Often on plantar surface.
DIF: Analysis
REF: Wound Types
OBJ: Differentiate ulcers
TOP: Assessment
A client presents with lower leg edema, brown discoloration, and a weeping wound near the
medial malleolus. What is the most likely diagnosis?
Correct Answer:
Chronic venous insufficiency
Expert Rationale:
Venous insufficiency results from valve failure, leading to blood pooling. Symptoms include
edema, hemosiderin staining, and irregular draining ulcers near the medial malleolus.
Why other options are incorrect:
• PAD: Presents with dry, pale skin.
• Cellulitis: Acute infection signs.
• DVT: Acute swelling without skin discoloration pattern.
DIF: Analysis
REF: Venous Disorders
OBJ: Identify venous insufficiency
TOP: Pathophysiology
A client is at risk for pressure injuries. Which intervention is most effective for prevention?
Correct Answer:
Reposition the client every 2 hours
Expert Rationale:
Frequent repositioning reduces prolonged pressure on tissues, improving circulation and
preventing ischemia that leads to pressure injuries.
Why other options are incorrect:
• Limiting movement: Increases risk.
• Moist skin: Increases breakdown risk.
• Low-protein diet: Impairs healing.
, DIF: Application
REF: Pressure Injury Prevention
OBJ: Prevent skin breakdown
TOP: Nursing Care
A client has full-thickness skin loss with visible bone. What stage pressure injury is this?
Correct Answer:
Stage 4
Expert Rationale:
Stage 4 pressure injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle,
indicating severe damage.
Why other options are incorrect:
• Stage 1: Intact skin only.
• Stage 2: Partial thickness.
• Stage 3: No exposed bone.
DIF: Knowledge
REF: Pressure Injuries
OBJ: Classify wounds
TOP: Assessment
A client with left-sided heart failure presents with shortness of breath and crackles. What is the
underlying cause?
Correct Answer:
Blood backing up into the pulmonary circulation
Expert Rationale:
Left-sided heart failure causes blood to back up into the lungs, leading to pulmonary edema,
dyspnea, orthopnea, and crackles.
Why other options are incorrect:
• Systemic venous congestion: Right-sided failure.
• Kidney failure: Not primary cause.
• Liver congestion: Right-sided failure.
DIF: Analysis
REF: Heart Failure
