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ATI ADULT MEDICAL SURGICAL NURSING – UNIT 10 Integumentary &
Burns 120 Questions with Rationales
SECTION 1: SKIN ASSESSMENT & DIAGNOSTICS
1. A nurse is assessing a client's skin. Which of the following is a
normal finding?
A. Uniform skin color without lesions
B. Jaundice
C. Cyanosis of lips and nail beds
D. Pallor of the conjunctiva
Answer: A
Rationale: Uniform skin color without lesions is normal.
Jaundice, cyanosis, and pallor indicate underlying conditions.
2. Which of the following is a sign of impaired skin integrity?
A. Erythema, warmth, and open areas
B. Cool, dry skin
C. Intact skin with no redness
D. Normal turgor
Answer: A
Rationale: Erythema, warmth, and open areas indicate
inflammation or infection and impaired integrity.
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3. A nurse is assessing skin turgor on an older adult. Which
finding is expected?
A. Increased skin elasticity
B. Decreased skin turgor due to loss of elasticity
C. No change with aging
D. Tight, shiny skin
Answer: B
Rationale: Aging causes loss of elasticity and decreased turgor,
especially in older adults.
4. Which of the following is a risk factor for pressure injury
development?
A. Immobility and incontinence
B. Regular repositioning
C. Good nutrition
D. Intact sensation
Answer: A
Rationale: Immobility, moisture, poor nutrition, and sensory
loss increase pressure injury risk.
5. A client has a pressure injury with non-blanchable erythema
of intact skin. The nurse should stage this as:
A. Stage 1
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B. Stage 2
C. Stage 3
D. Stage 4
Answer: A
Rationale: Stage 1 pressure injury is non-blanchable erythema
of intact skin.
6. A client has a pressure injury with partial-thickness loss of
dermis presenting as a shallow open ulcer with a red-pink
wound bed. This is:
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Answer: B
Rationale: Stage 2 involves partial-thickness loss with a red-pink
wound bed without slough.
7. A client has a full-thickness pressure injury with visible
subcutaneous fat but no bone, tendon, or muscle exposed. This
is:
A. Stage 2
B. Stage 3
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C. Stage 4
D. Unstageable
Answer: B
Rationale: Stage 3 is full-thickness skin loss with visible fat;
Stage 4 has exposed bone/tendon/muscle.
8. A client has a pressure injury with full-thickness tissue loss
and exposed bone. This is:
A. Stage 3
B. Stage 4
C. Deep tissue injury
D. Stage 2
Answer: B
Rationale: Stage 4 involves full-thickness loss with exposed
bone, tendon, or muscle.
9. Which of the following is a sign of a deep tissue pressure
injury?
A. Non-blanchable deep red, maroon, or purple discoloration of
intact skin
B. Shallow open ulcer
C. Full-thickness loss with slough
D. Serous-filled blister
ATI ADULT MEDICAL SURGICAL NURSING – UNIT 10 Integumentary &
Burns 120 Questions with Rationales
SECTION 1: SKIN ASSESSMENT & DIAGNOSTICS
1. A nurse is assessing a client's skin. Which of the following is a
normal finding?
A. Uniform skin color without lesions
B. Jaundice
C. Cyanosis of lips and nail beds
D. Pallor of the conjunctiva
Answer: A
Rationale: Uniform skin color without lesions is normal.
Jaundice, cyanosis, and pallor indicate underlying conditions.
2. Which of the following is a sign of impaired skin integrity?
A. Erythema, warmth, and open areas
B. Cool, dry skin
C. Intact skin with no redness
D. Normal turgor
Answer: A
Rationale: Erythema, warmth, and open areas indicate
inflammation or infection and impaired integrity.
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3. A nurse is assessing skin turgor on an older adult. Which
finding is expected?
A. Increased skin elasticity
B. Decreased skin turgor due to loss of elasticity
C. No change with aging
D. Tight, shiny skin
Answer: B
Rationale: Aging causes loss of elasticity and decreased turgor,
especially in older adults.
4. Which of the following is a risk factor for pressure injury
development?
A. Immobility and incontinence
B. Regular repositioning
C. Good nutrition
D. Intact sensation
Answer: A
Rationale: Immobility, moisture, poor nutrition, and sensory
loss increase pressure injury risk.
5. A client has a pressure injury with non-blanchable erythema
of intact skin. The nurse should stage this as:
A. Stage 1
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B. Stage 2
C. Stage 3
D. Stage 4
Answer: A
Rationale: Stage 1 pressure injury is non-blanchable erythema
of intact skin.
6. A client has a pressure injury with partial-thickness loss of
dermis presenting as a shallow open ulcer with a red-pink
wound bed. This is:
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Answer: B
Rationale: Stage 2 involves partial-thickness loss with a red-pink
wound bed without slough.
7. A client has a full-thickness pressure injury with visible
subcutaneous fat but no bone, tendon, or muscle exposed. This
is:
A. Stage 2
B. Stage 3
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C. Stage 4
D. Unstageable
Answer: B
Rationale: Stage 3 is full-thickness skin loss with visible fat;
Stage 4 has exposed bone/tendon/muscle.
8. A client has a pressure injury with full-thickness tissue loss
and exposed bone. This is:
A. Stage 3
B. Stage 4
C. Deep tissue injury
D. Stage 2
Answer: B
Rationale: Stage 4 involves full-thickness loss with exposed
bone, tendon, or muscle.
9. Which of the following is a sign of a deep tissue pressure
injury?
A. Non-blanchable deep red, maroon, or purple discoloration of
intact skin
B. Shallow open ulcer
C. Full-thickness loss with slough
D. Serous-filled blister
