Ch. 45 Alteration in Tissue integrity
The nurse is discussing skin disorders with a group of caregivers. Which caregiver statement indicates an understanding of tinea capitis? "That is an infection that you get under your fingernails." "I always tell my daughter to use her own hairbrush." "My son got that infection when he was at the swimming pool." "My husband had that once and his groin itched so much."
"I always tell my daughter to use her own hairbrush." Explanation: Ringworm of the scalp is called tinea capitis or tinea tonsurans. The most common cause is infection with Microsporum audouinii, which is transmitted from person to person through combs, towels, hats, barber scissors, or direct contact. A less common type, Microsporum canis, is transmitted from animal to child. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, TABLE 45.2 Management of Fungal Infections, p. 1658.
The nurse is caring for a child with a second-degree (partial-thickness) burn. What assessment findings would the nurse expect to observe? Edema with wet blistering skin Reddened and leathery skin Edema with dry or waxy-looking skin Peeling skin with eschar
Edema with wet blistering skin Explanation: Partial-thickness or second-degree burns are very painful and edematous and have a wet appearance or the presence of blisters. Third-degree (full-thickness) burns appear red, edematous, leathery, dry, or waxy and may display red or charred skin (eschar). Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INJURIES, p. 1670.
The nurse is caring for a child with a second-degree (partial-thickness) burn. What assessment findings would the nurse expect to observe? Edema with wet blistering skin Reddened and leathery skin Edema with dry or waxy-looking skin Peeling skin with eschar
Edema with wet blistering skin Explanation: Partial-thickness or second-degree burns are very painful and edematous and have a wet appearance or the presence of blisters. Third-degree (full-thickness) burns appear red, edematous, leathery, dry, or waxy and may display red or charred skin (eschar). Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INJURIES, p. 1670.
The nurse is caring for a client brought to a pediatric clinic for swelling in the lower extremities with reddened skin that has undefined borders and pits slightly when pressed. What is the most likely diagnosis of the client's skin alteration? cellulitis impetigo staphylococcal scalded skin syndrome cat scratch disease
cellulitis Explanation: Cellulitis is characterized by reddened or lilac-colored swollen skin that pits when pressed by the fingertips. Impetigo has superficial lesions that can be bullous or nonbullous. Staphylococcal scalded skin syndrome involves bullae that enlarge and rupture, leaving a red, scalded-looking lesion. Cat scratch disease involves a benign, subacute, chronic course of lymphadenopathy that usually resolves spontaneously in 2 to 3 months. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INFECTIOUS DISORDERS, p. 1655.
A nurse is teaching a group of parents about burn safety. Which statement made by a parent requires intervention by the nurse? "We installed smoke detectors on every floor in our home." "I always make sure the little ones stay out of the kitchen when I am cooking." "I had our plumber lower our water heater temperature to 130°F (53°C). "We made a song out of 'stop, drop and roll' to teach our children fire safety."
"I had our plumber lower our water heater temperature to 130°F (53°C). Explanation: Water heater temperature should be 120°F (49°C) or lower to prevent significant burns. Installing smoke detectors on every floor of a home is recommended. Keeping young children out of the kitchen during food preparation is important. Teaching children to stop, drop, and roll is important for fire safety. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INJURIES, p. 1675.
A nurse is providing teaching on ways to promote skin hydration for the parents of an infant with atopic dermatitis. Which response indicates a need for further teaching? "We need to avoid any skin product containing perfumes, dyes, or fragrances." "We should use a mild soap for sensitive skin." "We should bathe our child in hot water, twice a day." "We should use soap to clean only dirty areas."
"We should bathe our child in hot water, twice a day." Explanation: The nurse should emphasize that the parents should avoid hot water. The child should be bathed twice a day in warm water. The other statements are correct. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, Atopic Dermatitis, p. 1662.
A nurse is providing care to a hospitalized child who has burns over 40% of the body. The child is receiving intravenous fluid replacement with a 24 hour total of 3,216 ml. The nurse is administering the second half of the fluid between 0100 and 1700 hours. What rate should the nurse set the infusion pump? Record your answer using one decimal place.
100.5 Explanation: First, the nurse divides the total amount of fluid by 2, because there are two doses. 3216 mL ÷ 2 = 1608 ml Next, the nurse divides the single dose amount by the total number of hours, which is 16. 1608 mL ÷ 16 hours = 100.5 ml/hour Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INJURIES, p. 1673.
Which bathing technique demonstrates the nurse's correct knowledge when performing this intervention? A child should be bathed in lukewarm water with a mild soap and remain in the tub for a short time to avoid supersaturation. A child should be bathed in hot water with a mild soap and should remain in the tub for a short time to avoid supersaturation. A child should be bathed in lukewarm water with a mild soap and remain in the tub for a long period of time to achieve supersaturation. A child should have a bath in hot water with no soap to avoid irritation; the bath should last a short time to avoid supersaturation.
A child should be bathed in lukewarm water with a mild soap and remain in the tub for a short time to avoid supersaturation. Explanation: Bathe a child in lukewarm water. The bath should not last long enough for the skin to become supersaturated. Soaps and oils may be used during the bath to cleanse and moisturize the skin. Hot water should not be used in a child's bath in order to avoid additional skin irritation. The bath should not last long enough for the skin to become supersaturated. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, COMMON MEDICAL TREATMENTS 45.1, p. 1654.
The nurse is caring for a 9-year-old child with partial-thickness (second-degree) burns. The client rates the pain at an 8 on a 1 to 10 numerical pain scale. The nurse notes the client is sitting in the bed playing with toys and smiling. Which action will the nurse take? Administer pain medication as prescribed. Reassess the client's pain in 30 minutes. Ask the parents to rate the client's pain. Use another pain scale to measure the client's pain.
Administer pain medication as prescribed. Explanation: The nurse would administer the client pain medication as prescribed. Pain is how a client describes and rates it, regardless of outward appearances. The nurse should not allow the child to continue to feel pain while waiting an additional 30 minutes, asking the parents their opinion, or using a different pain scale. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INJURIES, p. 1670.
A nurse is providing care to an infant who is admitted with burns over the face, neck and chest. The nurse identifies which goal as priority for planning the infant's care? Airway remains patent. Pain is at a tolerable level. Wounds remain infection-free. Fluid balance is maintained.
Airway remains patent. Explanation: The priority goal is to maintain a patent airway especially because the burns affect the face and neck. Adequate output, maintaining pain at a tolerable level, and keeping the burns free from infection are all appropriate goals for this infant, but maintaining a patent airway is the priority. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, BOX 45.4 Emergency Assessment of the Burned Child, p. 1671.
A young child has just been admitted to the emergency department with a burn that encompasses the epidermis and the underlying dermis. From which type of burn does this child suffer? First-degree or superficial burn Second-degree or partial-thickness burn Third-degree or full-thickness burn Fourth-degree or fat-layer burn
Second-degree or partial-thickness burn Explanation: A burn that encompasses the epidermis and the underlying dermis is a second-degree burn. A first-degree burn would only involve the epidermis, and a third-degree burn would involve nerve endings as well as destruction of the epidermis and dermis. A fourth-degree burn would extend even deeper into the fat layer. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INJURIES, p. 1669.
The nurse is educating a parent about the treatment for a child's tinea cruris. What medication class would the nurse include in the teaching plan? corticosteroid antifungal antibiotic antihistamine
antifungal Explanation: Tinea cruris is a fungal infection of the groin area. Treatment would include antifungals. Antihistamines are typically used for the treatment of hypersensitivity and allergy disorders. Corticosteroids are used in the treatment of allergies and dermatitis. Antibiotics would be used to treat bacterial infections of the skin. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, TABLE 45.2 Management of Fungal Infections, p. 1658.
The nurse is discussing dietary intake with the parents of a 4-year-old child who has been diagnosed with atopic dermatitis. Later, the nurse notes the menu selection made by the parents for the child. Which selection indicates the need for further instruction? peanut butter and jelly sandwich chicken nuggets tomato soup carrot and celery sticks
peanut butter and jelly sandwich Explanation: Atopic dermatitis is commonly associated with allergies to food. Common culprits may include peanuts, eggs, orange juice, and wheat-containing products. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, Atopic Dermatitis, p. 1660.
The nurse is teaching parents about the care of diaper rash. The nurse would be concerned about the parents' level of understanding if they made which statement? "I need to wash and rinse clothes thoroughly to be sure all of the detergent is washed out." "I should not overdress the infant." "I should only use ointments and creams as instructed by the health care provider." "I should be certain to use fabric softener in the care of the infant's clothes."
"I should be certain to use fabric softener in the care of the infant's clothes." Explanation: Fabric softeners should be avoided because their use can result in skin irritation in the infant. Clothing and other baby items should be washed and rinsed thoroughly. Overdressing should be avoided as sweating irritates the rash, and only ointments and creams that are recommended by health care personnel should be used on the infant. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, Diaper Dermatitis, p. 1660.
What accurately depicts the hemodynamic changes that occur in the body within the first 24 to 48 hours after a burn? Hematocrit and white blood cell (WBC) counts increase. Hemoglobin and white blood cell (WBC) counts decrease. Hematocrit and white blood cell (WBC) counts decrease. Hematocrit increases and white blood cell (WBC) count decreases.
Hematocrit and white blood cell (WBC) counts increase. Explanation: In the first 24 to 48 hours after a burn, the hematocrit will often be elevated secondary to fluid loss and the WBC count may also be elevated as an acute-phase reaction, which later could indicate infection. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INJURIES, p. 1670.
A parent expresses a concern about white scales that have begun to flake off the 1-week-old infant's scalp. The parent asks, "What can I do to prevent this?" Which response by the nurse would be most appropriate? "Your child most likely has infantile seborrheic dermatitis, or cradle cap. You can care for it by cleansing the hair and scalp daily with baby shampoo. You can also apply baby oil to the area for 10 to 15 minutes and then rinse away the flakes." "Your child most likely has dandruff. You can treat it with daily with antiseborrheic shampoo, like Head and Shoulders." "How often do you bathe your infant? The infant should have a thorough shampooing every day to prevent things like this." "Your child most likely has infantile seborrheic dermatitis, or cradle cap. There is no intervention needed and it should resolve in 1 week."
"Your child most likely has infantile seborrheic dermatitis, or cradle cap. You can care for it by cleansing the hair and scalp daily with baby shampoo. You can also apply baby oil to the area for 10 to 15 minutes and then rinse away the flakes." Explanation: Infantile seborrheic dermatitis usually responds well to cleansing the scalp with a mild shampoo. The thick, scaling lesions on the child's scalp can be treated by applying baby oil, salicylic acid in mineral oil, or a corticosteroid gel on the scalp for 10 to 15 minutes. The area is gently massaged with a soft toothbrush; then the scales can be rinsed away. A fine-toothed comb helps rid the hair of scale debris. Antiseborrheic shampoo is not recommended for infants. Accusing a parent of poor hygiene is inappropriate. Infantile seborrheic dermatitis is not a result of poor hygiene. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INFLAMMATORY SKIN CONDITIONS, p. 1665.
A child enters the acute care setting following a burn injury. The nurse should check for which immunization booster? tetanus pertussis diphtheria meningitis
tetanus Explanation: For any burn, the nurse should check the child's tetanus immunization status on admission and ensure that tetanus toxoid is given if the child's immunizations are not up to date. Anaerobic and aerobic bacteria can grow at the interface between burned and healthy tissue, causing infection and possible sepsis. Pertussis, diphtheria, and meningitis are communicable diseases and, therefore, not related to burn injuries. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INJURIES, p. 1673.
The nurse is caring for an infant who has impetigo and is hospitalized. Which nursing action is priority? The nurse soaks the skin with warm water. The nurse applies topical antibiotics to the lesions. The nurse follows contact precautions. The nurse applies elbow restraints to the infant.
The nurse follows contact precautions. Explanation: Impetigo is highly contagious and can spread quickly. The nurse should follow contact (skin and wound) precautions, including wearing a cover gown and gloves. The nurse will soak the crusts with warm water, apply topical antibiotics, and apply elbow restraints, but these are not as high a priority as trying to prevent the spread of the infection by following contact precautions. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INFECTIOUS DISORDERS, p. 1657.
When assessing an adolescent for acne, what findings would lead the nurse to identify the acne as severe? Select all that apply. widespread inflammatory lesions evidence of cysts presence of nodules comedones facial papules
widespread inflammatory lesions evidence of cysts presence of nodules Explanation: Severe acne is characterized by inflammatory lesions such as papules or pustules that are widespread and/or the presence of cysts or nodules and possibly scarring. Comedones are associated with mild acne. Papules localized to the face or back are associated with moderate acne. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INFLAMMATORY SKIN CONDITIONS, p. 1667.
The parents of a child recently diagnosed with atopic dermatitis voice concern to the nurse that their child may develop asthma at some point. How should the nurse respond? "I am not sure why you think a skin disorder would lead to asthma?" "I can understand your concern. We will closely monitor your child for asthma development." "If your child starts having respiratory difficulties, be sure to let your health care provider know." "All children with atopic dermatitis develop both asthma and hay fever, so we will monitor your child for both conditions."
"I can understand your concern. We will closely monitor your child for asthma development." Explanation: Atopic dermatitis (eczema) is one of the disorders in the atopy family (along with asthma and allergic rhinitis [hay fever]). About 30% to 35% of children who have atopic dermatitis will also develop allergic rhinitis (hay fever) and/or asthma. Therefore, the child will be monitored for the development of asthma. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INFLAMMATORY SKIN CONDITIONS, p. 1660.
An 8-month-old has been diagnosed with infantile eczema. At a follow-up appointment, the child's caregiver seems exhausted and angry. He explains that he has done all of the child's care because his wife is repulsed by the child's raw and uncomfortable appearance. What responses would be appropriate for the nurse to say to this caregiver? "He will be better soon and your family can get back to normal." "I understand her feelings. It is hard to see a child in pain sometimes." "That's not fair to you; she should get some counseling to learn how to cope with illness better." "That's not an uncommon reaction, although it's hard on you and on your child."
"That's not an uncommon reaction, although it's hard on you and on your child." Explanation: The family caregivers of the child with eczema are often frustrated and exhausted. Family caregivers may feel apprehensive or repulsed by this unsightly child. Support them in expressing their feelings and help them view this as a distressing but temporary skin condition. Although the caregiver can be assured that most cases of eczema clear up by the age of 2, this does little to relieve the present situation. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, Atopic Dermatitis, p. 1662.
A pediatric client who has been seriously burned is being given IV fluid replacements. It has been determined that the client will initially need 24 ounces of replacement fluids. In following a normal burn replacement treatment for this child, if the treatment is started at 10:00 AM, which of the following would be correct? The child would have received: 12 ounces of IV fluid replacement by 4:00 PM. 12 ounces of IV fluid replacement by 6:00 PM. 18 ounces of IV fluid replacement by 4:00 PM. 18 ounces of IV fluid replacement by 6:00 PM.
12 ounces of IV fluid replacement by 6:00 PM. Explanation: Intravenous fluids for maintenance and replacement of lost body fluids are estimated for the first 24 hours, with half of this calculated requirement given during the first 8 hours. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INJURIES, p. 1672.
The nurse is developing the plan of care for a child who has suffered a major burn and has just been admitted to the acute care facility. Which nursing diagnosis would be most appropriate? Knowledge deficit related to daily care procedures in the acute care setting Risk for fluid volume overload related to thermal injuries Acute pain related to thermal injuries and procedures Risk for aspiration related to effects of medication
Acute pain related to thermal injuries and procedures Explanation: Management of acute pain is crucial for the client with a burn. Knowledge of the daily procedures at the acute care setting is not a priority for this client. A child with a burn would most likely experience fluid volume deficit due to the fluid loss associated with burns. Risk for aspiration would not be an appropriate nursing diagnosis. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INJURIES, p. 1673.
Which intervention is the most beneficial for a burn client undergoing a skin graft? Provide around-the-clock pain medication as soon as pain is reported. Provide pain medication on a PRN schedule as soon as pain is reported. Provide diversional activities for the client. Provide an egg-crate mattress or gel mattress for the client to lie upon.
Provide around-the-clock pain medication as soon as pain is reported. Explanation: When the child undergoes a procedure, such as skin grafting, that is known to produce prolonged pain, administer pain medication on a scheduled basis, rather than as needed once pain is reported. Around-the-clock pain medication will serve to diminish peaks and valleys in pain relief. Diversional activities and an egg-crate mattress are not effective treatments for severe pain. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INJURIES, p. 1675.
The nurse is caring for a child brought to a pediatric clinic for swelling in the lower extremities. The skin is reddened with undefined borders and pits slightly when pressed. Based on the assessment findings, which of the following would the nurse suspect? cellulitis impetigo staphylococcal scalded skin syndrome (SSSS) cat scratch disease
cellulitis Explanation: Cellulitis is characterized by reddened or lilac-colored, swollen skin that pits when pressed by the fingertips. Impetigo has superficial lesions that can be bullous or nonbullous. SSSS involves bullae that enlarge and rupture, leaving a red, scalded-looking lesion. Cat scratch disease involves a benign, subacute, chronic course of lymphadenopathy that usually resolves spontaneously in 2 to 3 months. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, TABLE 45.1 Bacterial Skin Infections, p. 1657.
A nurse is assessing a 6-month-old girl with an integumentary disorder. The nurse notes three virtually identically sized, round red circles with scaling that are symmetrically spaced on both of the girl's inner thighs. What should the nurse ask the mother? "Has she been exposed to poison ivy?" "Does she wear sleepers with metal snaps?" "Do you change her diapers regularly?" "Tell me about your family history of allergies."
"Does she wear sleepers with metal snaps?" Explanation: Small round red circles with scaling, symmetrically located on the girl's inner thighs, point to nickel dermatitis that may occur from contact with jewelry, eyeglasses, belts, or clothing snaps. The nurse should inquire about any sleepers or clothing with metal snaps. The girl does not have a rash in her diaper area. It is unlikely that an infant this age would have her inner thighs exposed to a highly allergenic plant. Discussing family allergy history is important, but the nurse should first inquire about any clothing with metal that could have come into contact with the girl's skin when she displays a symmetrical rash. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, Contact Dermatitis, p. 1663.
The clinic nurse is assessing a 12-year-old client. The client reports having dandruff and asks the nurse what can be done for it. Which response by the nurse is best? "Wash your hair with a gentle shampoo daily." "I will let your primary health care provider know you need prescription shampoo." "Wash your hair vigorously twice a day for one week." "Apply warm baby oil to your scalp once a day for a few days."
"Wash your hair with a gentle shampoo daily." Explanation: In the older child and adolescent, a gentle shampoo should be used daily to control scaling caused by dandruff. A medicated shampoo may be indicated if shampooing with a gentle formula shampoo does not provide relief. Washing hair vigorously twice a day is not recommended. Warm baby oil is recommended for infants with cradle cap (seborrhea). Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INFLAMMATORY SKIN CONDITIONS, p. 1665.
The nurse is interviewing the mother of a 6-month-old being seen at a well-child visit. The mother reports she has used an over-the-counter topical ointment intended for adults on her child for a skin rash. What is the most appropriate response by the nurse? "This is dangerous so please do not do this again." "Why did you do that instead of contacting your doctor?" "Children have thin skin and can absorb medications differently than adults." "How often do you use this medication?"
"Children have thin skin and can absorb medications differently than adults." Explanation: Children have thinner skin than adults. They will absorb topical medications more rapidly than adults. Medications concentrated for adults should not be used on children. It is important to explain this to the parent. It is confrontational to tell her this is dangerous or to tell her to contact the physician. The frequency of use is information that should be obtained but the education is most important in this scenario. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, VARIATIONS IN PEDIATRIC ANATOMY AND PHYSIOLOGY, p. 1650.
An adolescent is prescribed isotretinoin. Which statement indicates that the adolescent understands the necessary precautions associated with this drug? "I have to make sure that I do not become pregnant while taking this drug." "I'm going to have to have a blood count done every couple of months." "This drug can affect my lungs so I need a chest radiograph done first." "The drug might cause staining of my clothing."
"I have to make sure that I do not become pregnant while taking this drug." Explanation: Adolescent girls taking this drug who are sexually active must be on a pregnancy prevention program because the drug causes defects in fetal development. Monthly complete blood counts are required when taking isotretinoin. Isotretinoin is not associated with lung problems, so a chest radiograph is not necessary. Coal tar preparations are associated with staining of the clothing or fabrics. Isotretinoin does not stain clothes or fabrics. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, DRUG GUIDE 45.1 Common Drugs for Integumentary Disorders, p. 1655.
The nurse is caring for a child with a prescription for PO prednisone. Which statement by the child's mother would indicate a need for further education? "My child should take the entire prescription as prescribed by the health care provider." "I will give it to ny child at least 1 hour before all meals." "I will have to watch my child closely for signs of infection." "Since my child has type 1 diabetes, I will need to monitor my child's blood sugar levels closely while on this medication.
"I will give it to ny child at least 1 hour before all meals." Explanation: Systemic corticosteroids such as prednisone should be administered with food to decrease gastrointestinal upset. These medications may mask signs of infection. This medication may increase blood sugar levels. Corticosteroid doses should be tapered and should not be stopped abruptly. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, DRUG GUIDE 45.1 Common Drugs for Integumentary Disorders, p. 1655.
The nurse is caring for a child brought to the emergency department by the parents. Upon assessment the physician suspects the child has been bitten by a spider. While obtaining the nursing history of the present condition, which statement by the parent will require clarification from the nurse? "Since my child just has a rash around the area of the bite there is nothing to worry about." "My child plays in our woods a lot so I need to be sure protective clothing and shoes are worn." "I cleaned the wound with soap and water right away. I hope that's okay." "I put ice on the bite to try to keep the swelling down."
"Since my child just has a rash around the area of the bite there is nothing to worry about." Explanation: A rash could be an indication of a systemic reaction and the child should be monitored closely for other signs of a systemic, or possible anaphylactic, reaction. Protective clothing for the prevention of insect or spider bites, cleansing the wound to help with infection control, and ice for prevention of swelling are all effective actions. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, Insect Stings and Spider Bites, p. 1678.
The nurse instructor is reviewing the integumentary system during a presentation to a group of student nurses. Which statement made by the instructor is the most accurate regarding the integumentary system? "The sebaceous and sweat glands are fully functional in the infant." "The largest organ of the body helps regulate body temperature." "The integumentary system is not in place until after the child is born and then takes many years to mature." "One role of the integumentary system is to distribute oxygen to the body cells."
"The largest organ of the body helps regulate body temperature." Explanation: The skin is the largest organ of the body. The skin helps regulate the body temperature by heating and cooling. The sebaceous and sweat glands are not fully functional until middle childhood. The major role of the skin is to protect the organs and structures of the body against bacteria, chemicals, and injury. Excretion in the form of perspiration is also a function of the skin glands, called the sweat glands. Sebaceous glands in the skin secrete oils to lubricate the skin and hair. The integumentary system is in place at birth, but the system is immature. A function of the respiratory system is to distribute oxygen to body cells. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, VARIATIONS IN PEDIATRIC ANATOMY AND PHYSIOLOGY, p. 1650.
The nurse is caring for a child with burns. The child is scheduled to be discharged the following day, and the nurse is going over discharge instructions with the parents. After teaching the parents about caring for the burn, the nurse determines that the teaching was successful when the parents make which statement about removing an old dressing? "We'll take our time and be thorough when changing the burn dressing." "We'll take off the old dressing as quickly as we possibly can." "We'll soak the old dressing in cold normal saline before removing it." "We need to soak the old dressing in tepid water just before we take it off."
"We need to soak the old dressing in tepid water just before we take it off." Explanation: The nurse should instruct the parents to soak the dressing in tepid water before removing it to loosen the dressing and to decrease the child's discomfort. Removing the old dressing too quickly could cause stripping of new skin and tissue that is attached to the dressing. Dressing changes are done as quickly as possible once the old dressing has been removed because exposure to air and water causes pain. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INJURIES, p. 1672.
The dermatologist treating a 16-year-old girl with a history of severe acne has ordered a pregnancy test so she can be started on a course of isotretinoin. The teen's caregiver has said that her daughter is a virgin and she refuses to allow her to have the required pregnancy testing. What would be the best action for the nurse to take? Acknowledge the caregiver's discomfort about the pregnancy testing but encourage her to allow the daughter to have the testing so that she can use the medication. Speak with the teen alone to ask her if she is sexually active. If she says she is not sexually active, let the provider know that it is okay to write the prescription. Arrange for the daughter to have the pregnancy testing without the caregiver's knowledge. Have the caregiver sign a permission form acknowledging that the girl has been given the drug without pregnancy testing.
Acknowledge the caregiver's discomfort about the pregnancy testing but encourage her to allow the daughter to have the testing so that she can use the medication. Explanation: Isotretinoin is a pregnancy category X drug: It must not be used at all during pregnancy because of serious risk of fetal abnormalities. To rule out pregnancy, a urine test is done before beginning treatment. For the sexually active adolescent girl, an effective form of contraception must be used for a month before beginning and during isotretinoin therapy. The risk to the fetus, should pregnancy occur, should be discussed with the girl whether she is sexually active or not. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, DRUG GUIDE 45.1 Common Drugs for Integumentary Disorders, p. 1655.
An adolescent with tinea versicolor is admitted for treatment of the disorder. Which nursing diagnosis will the nurse identify as having the highest priority for this client? Risk for fluid volume deficit Disturbed body image Pain Altered nutrition
Disturbed body image Explanation: Tinea versicolor is a superficial tan or hypopigmented oval scaly lesions, especially on upper back and chest and proximal arms. It may take several months for pigmentation to return to normal; therefore, disturbed body image is going to be a high priority for an adolescent client. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, Nursing Process Overview for the Child with an Integumentary Disorder, p. 1653.
A parent is observing a nurse provide care for the parent's 2-year-old toddler who was burned in a house fire. When the nurse is finished, the parent tells the nurse "I cannot believe this has happened. I should have been able to prevent this from happening." What is the best action for the nurse to take? Give the parent a hug. Tell the parent to be thankful that the child is alive. Encourage the parent to talk more about feelings. Tell the parent he or she could not have prevented the fire
Encourage the parent to talk more about feelings. Explanation: The best action for the nurse to take is to encourage the parent to talk about his or her feelings. This gives the parent the opportunity to share feelings and concerns. Giving the parent a spontaneous hug may not be welcomed. Telling the parent he or she could not have prevented the fire or to be thankful that the child is alive is not therapeutic and negates the parent's feelings. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INJURIES, p. 1672.
A 30-month-old child has been discharged from the hospital after receiving treatment for second-degree (partial-thickness) burns over 6% of the body. One week later, the parent calls the nurse to say that the child has been drinking from a cup for one year, but is now constantly pulling at the mother's breast trying to nurse and refuses to drink from a cup. What is the best way for the nurse respond? Make an appointment for the parent to bring the child to the clinic for evaluation. Explain that children who have had a serious injury sometimes exhibit regressive behavior. Tell the parent to allow the child to nurse as much as the child wants. Encourage the parent to explain to the child that he or she must drink from the cup.
Explain that children who have had a serious injury sometimes exhibit regressive behavior. Explanation: The best response is for the nurse to explain that children recovering from serious injuries such as burns will often regress in their behaviors. There is no indication for the parent to bring the child to the clinic for evaluation. It is inappropriate to tell the parent to allow the child to nurse as much as he or she wants. If the child has been weaned for one year, the mother likely has no breast milk. At 30 months, the child may not understand fully that he or she cannot nurse any longer. The parent can be supportive to the child, comforting the child with hugs and cuddling, and reinforcing the desired behavior. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, Burns, p. 1669.
A parent brings an infant to the clinic for a well child visit. During the assessment, the parent asks the nurse why the infant never seems to sweat. What action should the nurse take? Make a note to inform the health care provider of the parent's concern. Explain that this normal mechanism keeps the infant from losing too much water through the skin. Tell the parent that the infant will need to see an endocrine specialist about the problem. Explain that this is because an infant's temperature normally runs lower than an adult's.
Explain that this normal mechanism keeps the infant from losing too much water through the skin. Explanation: The sweat glands of an infant are immature and this normal mechanism keeps the infant from losing too much insensible water. Because this is a normal occurrence, there is no reason to make a note to inform the health care provider or to refer the infant to a specialist. An infant's temperature does not run lower than an adult's temperature. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, VARIATIONS IN PEDIATRIC ANATOMY AND PHYSIOLOGY, p. 1650.
The community nurse receives a call from a local day care center. One of the children in the center has been diagnosed with impetigo. Which information related to impetigo will the nurse provide to the day care center? Impetigo is highly contagious and can spread quickly. Impetigo cannot be treated with medication and has to run its course. The facility staff should wear masks until all children and adults are healthy. Impetigo usually develops because of sensitivity to pollens and molds.
Impetigo is highly contagious and can spread quickly. Explanation: Impetigo is a highly contagious skin infection and can spread quickly. It usually appears as red sores on the face, especially around a child's nose and mouth, and may appear on the hands and feet. The sores burst and develop honey-colored crusts. It is spread by person-to-person contact, not droplet; therefore, masks are not indicated. It is treated with antibiotics, generally penicillin. The cause is not pollens or molds; it is bacterial. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INFECTIOUS DISORDERS, p. 1657.
An 8-year-old child requires wet dressings four times a day as treatment for a skin disorder. What would be most important for the nurse to do? Premedicate the child before changing the dressing. Elevate the area after performing the dressing change. Ensure that the temperature of the solution is 120°F (48.9°C). Use a fragrance-free, dye-free soap to clean the wound.
Premedicate the child before changing the dressing. Explanation: Premedicating the child before changing the dressing is crucial to providing atraumatic care. Elevating the area may or may not be appropriate depending on the problem and its location. A temperature of 120°F (48.9°C) is the recommended maximal hot water heater temperature. The solution for a wet dressing should not be this hot. There is no indication that the wound should be cleaned. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, COMMON MEDICAL TREATMENTS 45.1, p. 1654.
A mother asks the nurse about bathing her child. Which response by the nurse would be most appropriate? Use lukewarm water with a mild soap and allow the child to remain in the tub for a short time to avoid supersaturation. Make sure the water is hot and use a mild soap, letting the child stay in the tub until the water becomes cooled. Use lukewarm water with a mild soap and let the child play in the tub until his skin is supersaturated. Avoid using soap on his skin but keep the water hot to prevent him from becoming chilled.
Use lukewarm water with a mild soap and allow the child to remain in the tub for a short time to avoid supersaturation. Explanation: A child should be bathed in lukewarm water. The bath should not last long enough for the skin to become supersaturated. Soaps and oils may be used during the bath to cleanse and moisturize the skin. Hot water should not be used in a child's bath in order to avoid additional skin irritation and possible thermal injury. The bath should not last long enough for the skin to become supersaturated. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, COMMON MEDICAL TREATMENTS 45.1, p. 1654.
The nurse is caring for a 2-year-old boy with a burn. What finding would warrant referral to a burn unit? a chemical burn a superficial or first-degree burn on the hand a superficial or first-degree burn on the chest a superficial or first-degree burn on the upper arm
a chemical burn Explanation: According to the American Burn Association, chemical burns warrant referral to a burn unit. A partial-thickness or second-degree burn greater than 10% of the body surface area would warrant a referral to a burn unit. A superficial or first-degree burn on the chest or hands does not warrant a referral to a burn unit. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INJURIES, p. 1669.
The nurse is assessing a child who has had an open wound for the last 2 weeks with no signs of healing. The parents report they have been using over-the-counter antibiotic ointment with no signs of improvement. The child is active in football in the fall and the swim team in the winter. What disorder does the nurse suspect? impetigo community acquired MRSA staphylococcal scalded skin syndrome folliculitis
community acquired MRSA Explanation: Risk factors for community-acquired MRSA (CA-MRSA) are turf burns, towel sharing, participation in team sports, or attendance at day care or outdoor camps. The condition usually presents with a moderate to severe skin infection or with an infection that is not responding as expected to therapy. Impetigo is a readily recognizable skin rash infection. Staphylococcal scalded skin syndrome results from infection with S. aureus that produces a toxin, which then causes exfoliation, and it has abrupt onset. Folliculitis is an infection of a hair follicle. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INFECTIOUS DISORDERS, p. 1656.
The nurse is taking a health history of a 6-year-old girl with suspected Stevens-Johnson syndrome. During the physical examination, the nurse would expect to note which physical findings? erythema multiforme with inflammatory bullae of at least two types of mucosa fiery red lesions, scaling in the skin folds, and satellite lesions red macules and bullous eruptions on an erythematous base red, raised hair follicles
erythema multiforme with inflammatory bullae of at least two types of mucosa Explanation: Stevens-Johnson syndrome rash involves erythema multiforme with the addition of inflammatory bullae of at least two types of mucosa. Fiery red lesions, scaling in the skin folds, and satellite lesions are associated with diaper candidiasis. Red macules and bullous eruptions on an erythematous base are common skin findings for bullous impetigo. Red, raised hair follicles are indicative of folliculitis. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, BOX 45.1 Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis, p. 1664.
The nurse is conducting a physical examination of a boy with erythema multiforme. Which assessment finding should the nurse expect? lesions over the hands and feet, and extensor surfaces of the extremities with spread to the trunk thick or flaky/greasy yellow scales silvery or yellow-white scale plaques and sharply demarcated borders superficial tan or hypopigmented oval-shaped scaly lesions especially on upper back and chest and proximal arms
lesions over the hands and feet, and extensor surfaces of the extremities with spread to the trunk Explanation: Erythema multiforme typically manifests in lesions over the hands and feet, and extensor surfaces of the extremities with spread to the trunk. Thick or flaky/greasy yellow scales are signs of seborrhea. Silvery or yellow-white scale plaques and sharply demarcated borders define psoriasis. Superficial tan or hypopigmented oval-shaped scaly lesions, especially on the upper back and chest and proximal arms, are indicative of tinea versicolor. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, Erythema Multiforme, p. 1664.
The nurse is examining a child for indications of frostbite and notes blistering with erythema and edema. The nurse notes which degree of frostbite? first-degree frostbite second-degree frostbite third-degree frostbite fourth-degree frostbite
second-degree frostbite Explanation: Second-degree frostbite demonstrates blistering with erythema and edema. First-degree frostbite results in superficial white plaques with surrounding erythema. In third-degree frostbite, the nurse would note hemorrhagic blisters that would progress to tissue necrosis and sloughing when the fourth degree is reached. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INJURIES, p. 1677.
The nurse admits a child who has sustained a severe burn. The child's immunizations are up to date. Which immunization would the child most likely be given at this time? hepatitis A vaccine hepatitis B vaccine tetanus toxoid vaccine Haemophilus influenzae type B vaccine
tetanus toxoid vaccine Explanation: If inoculations are up to date, a booster dose of tetanus toxoid is required to protect the child from infection introduced into the burn. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, INJURIES, p. 1673.
The nurse is caring for a child with a skin disorder. The child presented with papules that progressed to vesicles with a honey-colored exudate. What treatment would the nurse expect to be ordered to treat this disorder? Select all that apply. topical mupirocin ointment warm compresses after washing with soap and water several times a day oral cephalexin cool compresses to assist in removing crusts on vesicles regular hygiene measures
topical mupirocin ointment cool compresses to assist in removing crusts on vesicles regular hygiene measures Explanation: Nonbullous impetigo symptoms include papules progressing to vesicles with honey-colored exudate when the vesicles rupture. Treatment includes topical mupirocin ointment with cool compresses twice per day to assist in removing the honey-colored crust. Oral cephalexin and good hygiene are used to treat bullous impetigo. Warm compresses after washing with soap are used to treat folliculitis. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, TABLE 45.1 Bacterial Skin Infections, p. 1657.
The nursing diagnosis of risk for infection related to a disruption in the protective skin barrier is noted on a child's plan of care. Which action would be of greatest importance? using appropriate hand hygiene assessing temperature every 4 hours urging adequate nutritional intake obtaining a culture of the impaired skin area
using appropriate hand hygiene Explanation: Hand hygiene would be the priority because the child's risk for infection is increased and hand hygiene is crucial to preventing the transmission of infectious organisms. Monitoring the child's temperature is important to evaluate for possible fever and infection, but this would not be the most important action. Although nutritional status can influence wound healing, urging adequate nutritional intake would not be the most important action. Although obtaining a culture provides information about the cause of an infection, the child is at risk for infection, so a culture would not provide any information about the risk. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 4th ed., Philadelphia, Wolters Kluwer, 2021, Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder, Nursing Process Overview for the Child with an Integumentary Disorder, p. 1653.