Patient Care Concepts for Skin Issues in Med-Surg
HPE1005 - Mental Health Issues
University of Cincinnati
Ignatavicius: Medical-Surgical Nursing, 10th Edition
Chapter 23: Concepts of Care for Patients with Skin Problems
Answer Key – NCLEX Examination Challenges, Clinical Judgment Challenges, and Mastery
Questions
Answer Key – NCLEX Examination Challenges
NCLEX Examination Challenge 23-1
Physiological Integrity
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which
assessment finding requires immediate nursing intervention?
A. Increased itching
B. Temperature 100°F
C. Presence of new plaques on leg
D. Expression of impaired self-image
Answer: C
Rationale: Use of a biologic therapy can depress the immune system. The client who has a
cough or fever could be showing signs and symptoms of an infection; thus, the nurse needs to
immediately intervene by completing an assessment, and then reporting this finding to the
health care provider immediately.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment/Evaluation
Physiological Integrity
When preparing to discharge a client who has a history of pediculosis, what teaching will the
nurse provide? Select all that apply.
A. Nits can be removed by a fine-tooth comb.
B. Parasites eventually die off without treatment.
C. Wash bed linens in hot water to remove lice and eggs.
D. Lice can live on clothing items and any surface that is covered by fabric.
E. Lice can infest anyplace on the body with hair, including eyelashes and axillae
Answers: A, C, D, E
Rationale: The nurse will teach that a fine-tooth comb can be used to remove nits; that bed
linens and clothing should be washing in hot water to remove lice and eggs; that lice can live
on clothing and fabric (and thus must be washed in hot water or dry cleaned); and that lice can
infest any body part that has hair. These parasites do not die off without treatment.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Health Promotion and Maintenance
When teaching a community group about burn prevention, which education will the nurse
include? Select all that apply.
A. “Have a smoke detector in one central spot in the home.”
B. “If you use home oxygen, turn it down when you are smoking.”
C. “Set your water heater temperature below 160 degrees F. (71 C.).”
D. “Plan several ways of escape from the home in case the primary exit is blocked.”*
Answer: D
Rationale: The nurse will teach that multiple routes of escape should be planned in case the
primary exit is blocked due to fire. Multiple smoke detectors should be used; not just one in a
central location. The client should never smoke around home oxygen. The water heater
temperature should be set below 120F (49C.) or burns may occur.
Cognitive Level: Application
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Physiological Integrity
A client with a large, irregular shaped mole on her upper chest expresses concern about the
cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a
dermatological health care provider.
B. Ask if there are any other lesions that bother her.
C. Perform a head-to-toe skin assessment and document the findings.
D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
Correct Answer: C
Rationale: The nurse will conduct a head-to-toe skin assessment and document the findings as
the priority; there may be other skin lesions that need attention. Once this is done, the nurse
can then query whether other lesions are bothersome, teach about avoidance of sun and tanning
beds, and refer the client to a dermatologic health care provider.
Cognitive Level: Analysis
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
Answer Key – Clinical Judgment Challenge 23-1
A 79-year old client with osteoporosis and urinary incontinence has been admitted to a long
term care facility after having an ischemic stroke. The client’s partner reports that before the
stroke, the client still needed help with ADLs. Assessment shows a slender, frail older adult
with significant left-sided weakness who requires assistance dressing, eating, and transferring
between the wheelchair to the bed. While assisting the client with change clothes, the nurse
notes a large reddened area on the left hip that doesn't change color when it is pressed on.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
It is important to note that the client has a large reddened area on the left hip that doesn’t blanch.
This is early indication of a forming pressure injury (Stage 1). The nurse will also note that the
client is frail and has significant unilateral weakness that may impact his or her ability to turn
and reposition, which can contribute to pressure injury formation or exacerbation. The
weakness is not completely new, as the client needed help before the stroke with ADLs, so the
nurse can anticipate that even at baseline, assistance in positioning and with skin care will be
needed. Notation of urinary incontinence is also important. If the client has urine continually
making contact with the skin, there is a higher risk for skin breakdown.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
A Stage 1 pressure injury is most consistent with the relevant information collected.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The explanation most likely is a Stage 1 pressure injury. This is definitely a serious condition,
as this type of injury can progress quickly without prompt, thorough intervention to prevent
loss of skin integrity.
4. What actions would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The actions that would achieve the desired outcome of preserving skin integrity include using
a skin bundle to provide care; continuous assessment and reassessment of the client’s skin;
keeping the skin clean and dry; checking regularly for incontinence (and cleaning as often as
needed); implementing pressure-reducing devices; and turning and repositioning the client at
least every two hours and more frequently as needed. Harmful actions include ignoring the
reddened area on the left hip, as this will allow the injury to progress.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
All actions listed in #4 should be implemented right away. These independent actions are
usually all incorporated in an evidence-based skin bundle.
6. What client assessment would indicate that the nurse’s actions were effective? (Hint:
Think about signs that would indicate an improvement, decline, or unchanged client condition.)
Resolution of the reddened area on the left hip would indicate that the nurse’s actions were
effective.
Answer Key – Mastery Question
Physiological Integrity
Which client statement regarding treatment of a skin infection requires intervention by the
nurse?
A. “I am not going to share my clothes with anyone else.”
B. “Because I am over 60, I am going to get the shingles vaccine.”
C. “It is important to keep my skin very moist, so I will use lotion.”
D. “If I get a fever or chills, I will contact my primary health care provider.”
Answer: C
Rationale: The nurse will intervene if the client states that lotion is needed to keep infected skin
moist. The skin actually needs to be kept clean and dry, and moisture can provide an
environment for bacteria to continue to thrive. The nurse does not need to intervene when the
client understands that clothing should not be shared, that the shingles vaccine is indicated for
individuals over 50, and that fever and chills should be reported to the primary health care
provider.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #2
Health Promotion and Maintenance
What teaching will the nurse provide when educating about carbon monoxide prevention?
A. “Carbon monoxide is only dangerous if accompanied by fire.”
B. “Black smoke can be seen when carbon monoxide is in the air.”
C. “Your skin will turn a blue color if you have carbon monoxide poisoning.”
D. “Put carbon monoxide detectors in your home, because this is an odorless gas.” *
Answer: D
Rationale: The nurse will teach that carbon monoxide prevention requires having carbon
monoxide detectors in the home. This is an odorless gas so regular senses do not pick up on the
presence of this gas, but carbon monoxide detectors can. The nurse will share that carbon
monoxide is dangerous in and of itself (not just when accompanied by fire); that it is colorless
and odorless; and that skin may turn reddish in the presence of carbon monoxide poisoning.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
NCLEX Mastery Question #3
Physiological Integrity
A client shows the nurse two pictures of the same lesion, taken one month apart. Which
assessment finding requires nursing intervention?
A. The light pink color of the lesion is the same in both photographs.
B. The lesion has almost disappeared by the time of the second photograph.
C. The lesion borders have expanded and are shaped differently in the second picture.
D. The lesion’s well-approximated margins and size look no different in either photograph.
Answer: C
Rationale: The nurse will intervene if the lesion’s borders have expanded and are shaped
differently, as this indicates a change in status that must be addressed. Lesions that are of the
same light pink color in both photographs do not require intervention at this time. Lesions that
have almost disappeared in this time frame do not require intervention at this time. Lesions that
have well-approximated margins and size that has not changed do not require intervention at
this time.
Cognitive Level: Application
Client Needs Category: Physiological Integrity
Nursing Process Step: Implementation
