ATI MENTAL HEALTH PROCTORED EXAM
1. The patient has a risk for skin impairment and has a 15 on the Braden Scale
upon admission. The nurse has implemented interventions. Upon
reassessment, which Braden score will be the best sign that the risk for skin
breakdown is removed?
a. 12
b. 13
c. 20
d. 23
ANS: D
The best sign is a perfect score of 23. The Braden Scale is composed of six
subscales: sensory perception, moisture, activity, mobility, nutrition, and friction
and shear. The total score ranges from 6 to 23, and a lower total score indicates a
higher risk for pressure ulcer development. The cutoff score for onset of pressure
ulcer risk with the Braden Scale in the general adult population is 18.
MULTIPLE RESPONSE
1. The nurse is caring for a patient with a surgical incision that eviscerates.
Which actions will the nurse take? (Select all that apply.)
a. Place moist sterile gauze over the site.
b. Gently place the organs back.
c. Contact the surgical team.
d. Offer a glass of water.
e. Monitor for shock.
ANS: A, C, E
The presence of an evisceration (protrusion of visceral organs through a wound
opening) is a surgical emergency. Immediately place damp sterile gauze over the
site, contact the surgical team, do not allow the patient anything by mouth (NPO),
observe for signs and symptoms of shock, and prepare the patient for emergency
surgery.
2. The nurse is caring for a patient with a wound healing by full-thickness
repair. Which phases will the nurse monitor for in this patient? (Select all that
apply.)
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,a. Hemostasis
b. Maturation
c. Inflammatory
d. Proliferative
e. Reproduction
f. Reestablishment of epidermal layers
ANS: A, B, C, D
The four phases involved in the healing process of a full-thickness wound are
hemostasis, inflammatory, proliferative, and maturation. Three components are
involved in the healing process of a partial-thickness wound: inflammatory
response, epithelial proliferation (reproduction) and migration, and
reestablishment of the epidermal layers.
3. The nurse is completing a skin assessment on a medical-surgical
patient. Which nursing assessment questions should be included in a skin
integrity assessment? (Select all that apply.)
a. “Can you easily change your position?”
b. “Do you have sensitivity to heat or cold?”
c. “How often do you need to use the toilet?”
d. “What medications do you take?”
e. “Is movement painful?”
f. “Have you ever fallen?”
ANS: A, B, C, E
Changing positions is important for decreasing the pressure associated with long
periods of time in the same position. If the patient is able to feel heat or cold and
is mobile, she can protect herself by withdrawing from
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, the source. Knowing toileting habits and any potential for incontinence is
important because urine and feces in contact with the skin for long periods
can increase skin breakdown. Knowing whether the patient has problems with
painful movement will alert the nurse to any potential for decreased
movement and increased risk for skin breakdown. Medications and falling are
safety risk questions.
4. The nurse is caring for a patient with potential skin breakdown. Which
components will the nurse include in the skin assessment? (Select all that
apply.)
a. Vision
b. Hyperemia
c. Induration
d. Blanching
e. Temperature of skin
ANS: B, C, D, E
Assessment of the skin includes both visual and tactile inspection. Assess for
hyperemia and palpate for blanching or nonblaching. Early signs of skin
damage include induration, bogginess (less-than-normal stiffness), and
increased warmth at the injury site compared to nearby areas. Changes in
temperature can indicate changes in blood flow to that area of the skin. Vision
is not included in the skin assessment.
5. The nurse is caring for a patient who will have both a large abdominal
bandage and an abdominal binder. Which actions will the nurse take before
applying the bandage and binder? (Select all that apply.)
a. Cover exposed wounds.
b. Mark the sites of all abrasions.
c. Assess the condition of current dressings.
d. Inspect the skin for abrasions and edema.
e. Cleanse the area with hydrogen peroxide.
f. Assess the skin at underlying areas for circulatory impairment.
ANS: A, C, D, F
Before applying a bandage or a binder, the nurse has several responsibilities.
1. The patient has a risk for skin impairment and has a 15 on the Braden Scale
upon admission. The nurse has implemented interventions. Upon
reassessment, which Braden score will be the best sign that the risk for skin
breakdown is removed?
a. 12
b. 13
c. 20
d. 23
ANS: D
The best sign is a perfect score of 23. The Braden Scale is composed of six
subscales: sensory perception, moisture, activity, mobility, nutrition, and friction
and shear. The total score ranges from 6 to 23, and a lower total score indicates a
higher risk for pressure ulcer development. The cutoff score for onset of pressure
ulcer risk with the Braden Scale in the general adult population is 18.
MULTIPLE RESPONSE
1. The nurse is caring for a patient with a surgical incision that eviscerates.
Which actions will the nurse take? (Select all that apply.)
a. Place moist sterile gauze over the site.
b. Gently place the organs back.
c. Contact the surgical team.
d. Offer a glass of water.
e. Monitor for shock.
ANS: A, C, E
The presence of an evisceration (protrusion of visceral organs through a wound
opening) is a surgical emergency. Immediately place damp sterile gauze over the
site, contact the surgical team, do not allow the patient anything by mouth (NPO),
observe for signs and symptoms of shock, and prepare the patient for emergency
surgery.
2. The nurse is caring for a patient with a wound healing by full-thickness
repair. Which phases will the nurse monitor for in this patient? (Select all that
apply.)
195
,a. Hemostasis
b. Maturation
c. Inflammatory
d. Proliferative
e. Reproduction
f. Reestablishment of epidermal layers
ANS: A, B, C, D
The four phases involved in the healing process of a full-thickness wound are
hemostasis, inflammatory, proliferative, and maturation. Three components are
involved in the healing process of a partial-thickness wound: inflammatory
response, epithelial proliferation (reproduction) and migration, and
reestablishment of the epidermal layers.
3. The nurse is completing a skin assessment on a medical-surgical
patient. Which nursing assessment questions should be included in a skin
integrity assessment? (Select all that apply.)
a. “Can you easily change your position?”
b. “Do you have sensitivity to heat or cold?”
c. “How often do you need to use the toilet?”
d. “What medications do you take?”
e. “Is movement painful?”
f. “Have you ever fallen?”
ANS: A, B, C, E
Changing positions is important for decreasing the pressure associated with long
periods of time in the same position. If the patient is able to feel heat or cold and
is mobile, she can protect herself by withdrawing from
196
, the source. Knowing toileting habits and any potential for incontinence is
important because urine and feces in contact with the skin for long periods
can increase skin breakdown. Knowing whether the patient has problems with
painful movement will alert the nurse to any potential for decreased
movement and increased risk for skin breakdown. Medications and falling are
safety risk questions.
4. The nurse is caring for a patient with potential skin breakdown. Which
components will the nurse include in the skin assessment? (Select all that
apply.)
a. Vision
b. Hyperemia
c. Induration
d. Blanching
e. Temperature of skin
ANS: B, C, D, E
Assessment of the skin includes both visual and tactile inspection. Assess for
hyperemia and palpate for blanching or nonblaching. Early signs of skin
damage include induration, bogginess (less-than-normal stiffness), and
increased warmth at the injury site compared to nearby areas. Changes in
temperature can indicate changes in blood flow to that area of the skin. Vision
is not included in the skin assessment.
5. The nurse is caring for a patient who will have both a large abdominal
bandage and an abdominal binder. Which actions will the nurse take before
applying the bandage and binder? (Select all that apply.)
a. Cover exposed wounds.
b. Mark the sites of all abrasions.
c. Assess the condition of current dressings.
d. Inspect the skin for abrasions and edema.
e. Cleanse the area with hydrogen peroxide.
f. Assess the skin at underlying areas for circulatory impairment.
ANS: A, C, D, F
Before applying a bandage or a binder, the nurse has several responsibilities.
