Chapter 32
3. The nurse is taking care of a 2-year-old child with a macule skin lesion. Which clinical finding should the nurse expect to assess with this type of lesion? a. Flat, nonpalpable, and irregularly shaped lesion that is greater than 1 cm in diameter b. Heaped-up keratinized cells, flaky exfoliation, irregular, thick or thin, dry or oily, varied in size c. Flat, brown mole less than 1 cm in diameter d. Elevated, flat-topped, firm, rough, superficial papule greater than 1 cm in diameter
ANS: C A macule is flat; nonpalpable; circumscribed; less than 1 cm in diameter; and brown, red, purple, white, or tan. A patch is a flat, nonpalpable, and irregularly shaped macule that is greater than 1 cm in diameter. Scale is heaped-up keratinized cells, flaky exfoliation, irregular, thick or thin, dry or oily, varied in size, and silver white or tan. A plaque is an elevated, flat-topped, firm, rough, superficial papule greater than 1 cm in diameter. It may be coalesced papules. PTS: 1 DIF: Cognitive Level: Understand REF: 1011 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. Which should the nurse include when teaching parents about preventing childhood burn injuries? (Select all that apply.) a. Keep hot liquids out of reach. b. Baby-proof electrical outlets. c. Turn water heater thermostats to a maximum of 150° F. d. Heat infant formula in the microwave. e. Test water temperature before placing your child in the tub bath.
, ANS: A, B, E To prevent burns hot liquids should be kept out of reach; tablecloths and dangling appliance cords are often pulled by toddlers, who spill hot grease and liquids on themselves. Electrical cords and outlets represent a potential risk to small children, who may chew on accessible cords and insert objects into outlets. The Consumer Product Safety Commission recommends a reduction of water heater thermostats to a maximum of 48.9° C (120° F). The increased use of microwave ovens has resulted in burn injuries from the extremely hot internal temperatures generated in heated items. Baby formula, jelly-filled pastries, and hot liquids and dishes may result in cutaneous scalds or the ingestion of overheated liquids. Water should always be tested before a child is placed in the tub or shower. PTS: 1 DIF: Cognitive Level: Apply REF: 1033 | 1047 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
1. A nurse is caring for a 5-year-old child with a major burn. The health care provider has written a prescription to notify the health care provider if urine output falls to or below 2 ml/kg/hr. The child weighs 55 lb. The nurse should notify the health care provider if the milliliters of urine output is at or below _____ for an hour. (Record your answer in a whole number.)
ANS: 50 The primary emphasis during the emergent phase is the treatment of burn shock and the management of pulmonary status. Monitoring vital signs, output, fluid infusion, and respiratory parameters are ongoing activities in the hours immediately after injury. IV infusion is begun immediately and is regulated to maintain a urinary output of at least 1 to 2 ml/kg in children weighing less than 30 kg (66 pounds). To calculate the child's weight in kilograms, the weight in pounds is divided by 2.2. That number is then multiplied by 2 to get the amount expected for a 1-hour period. 55/2.2 = 25 kg. 25 kg × 2 ml = 50 ml per hour. PTS: 1 DIF: Cognitive Level: Analyze REF: 1044 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
1. The nurse is taking care of a 7-year-old child with a skin rash called a papule. Which clinical finding should the nurse expect to assess with this type of skin rash? a. A lesion that is elevated, palpable, firm and circumscribed; less than 1 cm in diameter b. A lesion that is elevated, flat-topped, firm, rough and superficial; greater than 1 cm in diameter c. An elevated lesion, firm, circumscribed, palpable; 1 to 2 cm in diameter d. An elevated lesion, circumscribed, filled with serous fluid; less than 1 cm in diameter
ANS: A A papule is elevated; palpable; firm; circumscribed; less than 1 cm in diameter; and brown, red, pink, tan, or bluish red. A plaque is an elevated, flat-topped, firm, rough, superficial papule greater than 1 cm in diameter. It may be coalesced papules. A nodule is elevated, 1 to 2 cm in diameter, firm, circumscribed, palpable, and deeper in the dermis than a papule. A vesicle is elevated, circumscribed, superficial, less than 1 cm in diameter, and filled with serous fluid.
20. The management of a child who has just been stung by a bee or wasp should include the application of: a. cool compresses. b. warm compresses. c. antibiotic cream. d. corticosteroid cream.
ANS: A Bee or wasp stings are initially treated by carefully removing stinger, cleansing with soap and water, applying cool compresses, and using common household agents such as lemon juice or a paste made with aspirin and baking soda. Warm compresses are avoided. Antibiotic cream is unnecessary unless a secondary infection occurs. Corticosteroid cream is not part of the initial therapy. If a severe reaction occurs, systemic corticosteroids may be indicated. PTS: 1 DIF: Cognitive Level: Apply REF: 1025 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
48. Which is an effective strategy to reduce the stress of burn dressing procedures? a. Give child as many choices as possible. b. Reassure child that dressing changes are not painful. c. Explain to child why analgesics cannot be used. d. Encourage child to master stress with controlled passivity.
ANS: A Children who understand the procedure and have some perceived control demonstrate less maladaptive behavior. They respond well to participating in decisions and should be given as many choices as possible. The dressing change procedure is painful and stressful. Misinformation should not be given to the child. Analgesia and sedation can and should be used. Encouraging the child to master stress with controlled passivity is not a positive coping strategy. PTS: 1 DIF: Cognitive Level: Apply REF: 1046-1047 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Psychosocial Integrity: Coping and Adaptation
7. The nurse is caring for a 5-year-old child with impetigo contagiosa. The parents ask the nurse what will happen to their child's skin after the infection has subsided and healed. Which answer should the nurse give? a. There will be no scarring. b. There may be some pigmented spots. c. It is likely there will be some slightly depressed scars. d. There will be some atrophic white scars.
ANS: A Impetigo contagiosa tends to heal without scarring unless a secondary infection occurs. PTS: 1 DIF: Cognitive Level: Apply REF: 1018 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
31. When is isotretinoin (Accutane) indicated for the treatment of acne during adolescence? a. The acne has not responded to other treatments. b. The adolescent is or may become pregnant. c. The adolescent is unable to give up foods causing acne. d. Frequent washing with antibacterial soap has been unsuccessful.
ANS: A Isotretinoin is reserved for severe cystic acne that has not responded to other treatments. Isotretinoin has teratogenic effects and should never be used when there is a possibility of pregnancy. No correlation exists between foods and acne. Antibacterial soaps are ineffective. Frequent washing with antibacterial soap is not a recommended therapy for acne. PTS: 1 DIF: Cognitive Level: Understand REF: 1037 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
18. Which is usually the only symptom of pediculosis capitis (head lice)? a. Itching b. Vesicles c. Scalp rash d. Localized inflammatory response
ANS: A Itching is generally the only manifestation of pediculosis capitis (head lice). Diagnosis is made by observation of the white eggs (nits) on the hair shaft. Vesicles, scalp rash, and localized inflammatory response are not symptoms of head lice. PTS: 1 DIF: Cognitive Level: Understand REF: 1027 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
9. The nurse is conducting a staff in-service on appearance of childhood skin conditions. Lymphangitis ("streaking") is frequently seen in which condition? a. Cellulitis b. Folliculitis c. Impetigo contagiosa d. Staphylococcal scalded skin
ANS: A Lymphangitis is frequently seen in cellulitis. If it is present, hospitalization is usually required for parenteral antibiotics. Lymphangitis is not associated with folliculitis, impetigo, or staphylococcal scalded skin. PTS: 1 DIF: Cognitive Level: Understand REF: 1018 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
45. A child with extensive burns requires débridement. The nurse should anticipate which priority goal related to this procedure? a. Reduce pain. b. Prevent bleeding. c. Maintain airway. d. Restore fluid balance.
ANS: A Partial-thickness burns require débridement of devitalized tissue to promote healing. The procedure is painful and requires analgesia and sedation before the procedure. Preventing bleeding, maintaining the airway, and restoring fluid balance are not goals associated with débridement. PTS: 1 DIF: Cognitive Level: Apply REF: 1043 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
32. A child experiences frostbite of the fingers after prolonged exposure to the cold. Which intervention should the nurse implement first? a. Rapid rewarming of the fingers by placing in warm water b. Placing the hand in cool water c. Slow rewarming by wrapping in warm cloth d. Using an ice pack to keep cold until medical intervention is possible
ANS: A Rapid rewarming is accomplished by immersing the part in well-agitated water at 37.8° to 42.2° C (100° to 108° F). The frostbitten area should be rewarmed as soon as possible to avoid further tissue damage. Rapid rewarming results in less tissue necrosis than slow thawing. PTS: 1 DIF: Cognitive Level: Apply REF: 1048 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
36. The most immediate threat to life in children with thermal injuries is: a. shock. b. anemia. c. local infection. d. systemic sepsis.
ANS: A The immediate threat to life in children with thermal injuries is airway compromise and profound shock. Anemia is not of immediate concern. During the healing phase, local infection or sepsis are the primary complications. Respiratory problems, primarily airway compromise, are the primary complications during the acute stage of burn injury. PTS: 1 DIF: Cognitive Level: Apply REF: 1040 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
44. Hydrotherapy is required to treat a child with extensive partial-thickness burn wounds. Which is the primary purpose of hydrotherapy? a. Débride the wounds. b. Increase peripheral blood flow. c. Provide pain relief. d. Destroy bacteria on the skin.
ANS: A The water acts to loosen and remove sloughing tissue, exudate, and topical medications. Increasing peripheral blood flow, providing pain relief, and destroying bacteria on the skin may be secondary benefits to hydrotherapy, but the primary purpose is for débridement. PTS: 1 DIF: Cognitive Level: Apply REF: 1043 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
15. The nurse is caring for a school-age child with a tinea capitis (ringworm) infection. The nurse should expect that therapeutic management for this child includes: a. administering oral griseofulvin. b. administering topical or oral antibiotics. c. applying topical sulfonamides. d. applying Burow solution compresses to affected area.
ANS: A Treatment with the antifungal agent griseofulvin is part of the treatment for the fungal disease ringworm. Oral griseofulvin therapy frequently continues for weeks or months. Antibiotics, sulfonamides, and Burow solution are not effective in fungal infections. PTS: 1 DIF: Cognitive Level: Understand REF: 1020 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
1. Where do the lesions of atopic dermatitis (eczema) most commonly occur in the infant? (Select all that apply.) a. Cheeks b. Buttocks c. Extensor surfaces of arms and legs d. Back e. Trunk f. Scalp
ANS: A, C, E, F The lesions of atopic dermatitis are generalized in the infant. They are most commonly on the cheeks, scalp, trunk, and extensor surfaces of the extremities. The buttocks and back are not common locations for the lesions of atopic dermatitis in infants. PTS: 1 DIF: Cognitive Level: Understand REF: 1032 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
, 4. The community health nurse is teaching parents about prevention of the spread and reoccurrence of pediculosis (head lice). Which should the nurse include in the teaching session? (Select all that apply.) a. Dryclean nonwashable items. b. Spray the environment with an insecticide. c. Seal nonwashable items in a plastic bag for 5 days. d. Boil combs and brushes for 10 minutes. e. Discourage sharing of personal items.
ANS: A, D, E To prevent the spread and reoccurrence of pediculosis the nurse should teach the parents to: dryclean nonwashable items, boil combs and brushes for 10 minutes or soak for 1 hour in a pediculicide, and discourage the sharing of personal items, such as combs, hats, scarves and other headgear. Spraying with insecticide is not recommended because of the danger to children and animals. Nonwashable items should be sealed for 14 days in a plastic bag. PTS: 1 DIF: Cognitive Level: Apply REF: 1028 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
25. The nurse is examining 12-month-old Amy, who was brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with satellite lesions that cross the inguinal folds. This is most likely caused by: a. impetigo. b. Candida albicans. c. urine and feces. d. infrequent diapering.
ANS: B C. albicans infection produces perianal inflammation and a maculopapular rash with satellite lesions that may cross the inguinal folds. Impetigo is a bacterial infection that spreads peripherally in sharply marginated, irregular outlines. Eruptions involving the skin in contact with the diaper, but sparing the folds, are likely to be caused by chemical irritation, especially urine and feces. PTS: 1 DIF: Cognitive Level: Analyze REF: 1032 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
34. A child is admitted with extensive burns. The nurse notes that there are burns on the child's lips and singed nasal hairs. The nurse should suspect that the child has a(n): a. chemical burn. b. inhalation injury. c. electrical burn. d. hot-water scald.
ANS: B Evidence of an inhalation injury is burns of the face and lips, singed nasal hairs, and laryngeal edema. Clinical manifestation may be delayed for up to 24 hours. Chemical burns, electrical burns, and those associated with hot-water scalds would not cause singed nasal hair. PTS: 1 DIF: Cognitive Level: Understand REF: 1040 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
49. Which is an important consideration for the nurse when changing dressings and applying topical medication to a child's abdomen and leg burns? a. Apply topical medication with clean hands. b. Wash hands and forearms before and after dressing change. c. If dressings adhere to the wound, soak in hot water before removal. d. Apply dressing so that movement is limited during the healing process.
ANS: B Frequent hand and forearm washing is the single most important element of the infection-control program. Topical medications should be applied with a tongue blade or gloved hand. Dressings that have adhered to the wound can be removed with tepid water or normal saline. Dressings are applied with sufficient tension to remain in place but not so tightly as to impair circulation or limit motion. PTS: 1 DIF: Cognitive Level: Apply REF: 1045 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
40. A toddler sustains a minor burn on the hand from hot coffee. Which is the first action the nurse should recommend in treating this burn? a. Apply ice to burned area. b. Hold burned area under cool running water. c. Break any blisters with a sterile needle. d. Cleanse wound with soap and warm water.
ANS: B In minor burns, the best method to stop the burning process is to hold the burned area under cool running water. Ice is not recommended. Removal of blisters is not generally accepted therapy unless the injury is from a chemical substance. Cooling is necessary to stop the burning process. PTS: 1 DIF: Cognitive Level: Apply REF: 1041 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
11. The nurse should implement which prescribed treatment for a child with warts? a. Vaccination b. Local destruction c. Corticosteroids d. Specific antibiotic therapy
ANS: B Local destructive therapy individualized according to location, type, and number—including surgical removal, electrocautery, curettage, cryotherapy, caustic solutions, x-ray treatment, and laser therapies—is used. Vaccination is prophylaxis for warts and is not a treatment. Corticosteroids and specific antibiotic therapy are not effective in the treatment of warts. PTS: 1 DIF: Cognitive Level: Apply REF: 1019 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
14. Tinea capitis (ringworm), frequently found in schoolchildren, is caused by a(n): a. virus. b. fungus. c. allergic reaction. d. bacterial infection.
ANS: B Ringworm is caused by a group of closely related filamentous fungi that invade primarily the stratum corneum, hair, and nails. They are superficial infections that live on, not in, the skin. Virus and bacterial infection are not the causative organisms for ringworm. Ringworm is not an allergic response. PTS: 1 DIF: Cognitive Level: Understand REF: 1020 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
23. Rocky Mountain spotted fever is caused by the bite of a: a. flea. b. tick. c. mosquito. d. mouse or rat.
ANS: B Rocky Mountain spotted fever is caused by a tick. The tick must attach and feed for at least 1 to 2 hours to transmit the disease. The usual habitat of the tick is in heavily wooded areas. Fleas, mosquitoes, and mice or rats do not transmit Rocky Mountain spotted fever. PTS: 1 DIF: Cognitive Level: Understand REF: 1026 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
26. The nurse is teaching a class on preventing diaper rash in newborns to a group of new parents. Which statement made by a parent indicates a correct understanding of the teaching? a. "I should cleanse my infant's skin with a commercial diaper wipe every time I change the diaper." b. "If my infant's buttocks become slightly red, I will expose the skin to air." c. "I should wash my infant's buttocks with soap before applying a thin layer of oil." d. "I will apply baby oil and powder to the creases in my infant's buttocks."
ANS: B Slightly irritated skin can be exposed to air, not heat, to dry completely. Overwashing or cleansing the skin every diaper change with commercial wipes should be avoided. The skin should be thoroughly dried after washing. Application of oil does not create an effective barrier. Baby powder should not be used because of the danger of aspiration. PTS: 1 DIF: Cognitive Level: Apply REF: 1032-1033 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
46. Biologic dressings are applied to a child with partial-thickness burns of both legs. Which nursing intervention should be implemented? a. Observing wounds for bleeding b. Observing wounds for signs of infection c. Monitoring closely for signs of shock d. Splinting legs to prevent movement
ANS: B When applied early to a superficial partial-thickness injury, biologic dressings stimulate epithelial growth and hasten wound healing. If the dressing covers areas of heavy microbial contamination, infection occurs beneath the dressing. In the case of partial-thickness burns, such infection may convert the wound to a full-thickness injury. Infection is the primary concern when biologic dressings are used. PTS: 1 DIF: Cognitive Level: Apply REF: 1043 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. The nurse is talking to a parent of an infant with severe atopic dermatitis (eczema). Which response(s) should the nurse reinforce with the parent? (Select all that apply.) a. "You can use warm wet compresses to relieve discomfort." b. "You will need to keep your infant's skin well hydrated by using a mild soap in the bath." c. "You should bathe your baby in a bubble bath two times a day." d. "You will need to prevent your baby from scratching the area by using a mild antihistamine." e. "You can try a fabric softener in the laundry to avoid rough cloth." f. "You should apply an emollient to the skin immediately after a bath."
ANS: B, D, F The eczematous lesions of atopic dermatitis are intensely pruritic. Scratching can lead to new lesions and secondary infection; an antihistamine can be used. Keeping the skin hydrated is a goal of treating atopic dermatitis. Applying an emollient immediately after a bath helps to trap moisture and prevent moisture loss. Cool wet compresses should be used for relief. Bubble baths and harsh soaps should be avoided, as is bathing excessively, since this leads to drying. Fabric softener should be avoided because of the irritant effects of some of its components. PTS: 1 DIF: Cognitive Level: Apply REF: 1034 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
6. Which nursing consideration is important when caring for a child with impetigo contagiosa? a. Apply topical corticosteroids to decrease inflammation. b. Carefully remove dressings so as not to dislodge undermined skin, crusts, and debris. c. Carefully wash hands and maintain cleanliness when caring for an infected child. d. Examine child under a Wood lamp for possible spread of lesions.
ANS: C A major nursing consideration related to bacterial skin infections, such as impetigo contagiosa, is to prevent the spread of the infection and complications. This is done by thorough hand washing before and after contact with the affected child. Corticosteroids are not indicated in bacterial infections. Dressings are usually not indicated. The undermined skin, crusts, and debris are carefully removed after softening with moist compresses. A Wood lamp is used to detect fluorescent materials in the skin and hair. It is used in certain disease states, such as tinea capitis. PTS: 1 DIF: Cognitive Level: Understand REF: 1017 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
33. Which best describes a full-thickness (third-degree) burn? a. Erythema and pain b. Skin showing erythema followed by blister formation c. Destruction of all layers of skin evident with extension into subcutaneous tissue d. Destruction injury involving underlying structures such as muscle, fascia, and bone
ANS: C A third-degree, or full-thickness, burn is a serious injury that involves the entire epidermis and dermis and extends into the subcutaneous tissues. Erythema and pain are characteristic of a first-degree, or superficial, burn. Erythema with blister formation is characteristic of a second-degree, or partial-thickness, burn. A fourth-degree burn is a full-thickness burn that also involves underlying structures such as muscle, fascia, and bone. PTS: 1 DIF: Cognitive Level: Understand REF: 1039 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
47. Which is one of the first signs of overwhelming sepsis in a child with burn injuries? a. Seizures b. Bradycardia c. Disorientation d. Decreased blood pressure
ANS: C Disorientation in the burn patient is one of the first signs of overwhelming sepsis and may indicate inadequate hydration. Seizures, bradycardia, and decreased blood pressure are not initial manifestations of overwhelming sepsis. PTS: 1 DIF: Cognitive Level: Understand REF: 1046 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
42. Fentanyl and midazolam (Versed) are given before débridement of a child's burn wounds. Which is the rationale for administration of these medications? a. Promote healing. b. Prevent infection. c. Provide pain relief. d. Limit amount of débridement that will be necessary.
ANS: C Fentanyl and midazolam provide excellent intravenous sedation and analgesia to control procedural pain in children with burns. These drugs are for sedation and pain control, not healing, preventing infection, or limiting the amount of débridement. PTS: 1 DIF: Cognitive Level: Understand REF: 1042 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
24. The school nurse is conducting a class for school-age children on Lyme disease. Which is characteristic of Lyme disease? a. Difficult to prevent b. Treated with oral antibiotics in stages 1, 2, and 3 c. Caused by a spirochete that enters the skin through a tick bite d. Common in geographic areas where the soil contains the mycotic spores that cause the disease
ANS: C Lyme disease is caused by Borrelia burgdorferi, a spirochete spread by ticks. The early characteristic rash is erythema migrans. Tick bites should be avoided by entering tick-infested areas with caution. Light-colored clothing should be worn to identify ticks easily. Long-sleeved shirts and long pants tucked into socks should be the attire. Early treatment of the erythema migrans (stage 1) can prevent the development of Lyme disease. Lyme disease is caused by a spirochete, not mycotic spores. PTS: 1 DIF: Cognitive Level: Understand REF: 1029 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
13. The nurse is taking care of a 7-year-old child with herpes simplex virus (type 1 or 2). Which prescribed medication should the nurse expect to be included in the treatment plan? a. Corticosteroids b. Oral griseofulvin c. Oral antiviral agent d. Topical and/or systemic antibiotic
ANS: C Oral antiviral agents are effective for viral infections such as herpes simplex. Corticosteroids are not effective for viral infections. Griseofulvin is an antifungal agent and not effective for viral infections. Antibiotics are not effective in viral diseases. PTS: 1 DIF: Cognitive Level: Apply REF: 1019 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
5. A child steps on a nail and sustains a puncture wound of the foot. Which is the most appropriate method for cleansing this wound? a. Wash wound thoroughly with chlorhexidine. b. Wash wound thoroughly with povidone-iodine. c. Soak foot in warm water and soap. d. Soak foot in solution of 50% hydrogen peroxide and 50% water.
ANS: C Puncture wounds should be cleansed by soaking the foot in warm water and soap. Chlorhexidine, hydrogen peroxide, and povidone-iodine should not be used because they have a cytotoxic effect on healthy cells and minimal effect on controlling infection. PTS: 1 DIF: Cognitive Level: Apply REF: 1016 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
17. The nurse is taking care of a child with scabies. Which primary clinical manifestation should the nurse expect to assess with this disease? a. Edema b. Redness c. Pruritus d. Maceration
ANS: C Scabies is caused by the scabies mite. The inflammatory response and intense itching occur after the host has become sensitized to the mite. This occurs approximately 30 to 60 days after initial contact. Edema, redness, and maceration are not observed in scabies. PTS: 1 DIF: Cognitive Level: Understand REF: 1024 | 1026 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
29. Nursing care of the infant with atopic dermatitis focuses on: a. feeding a variety of foods. b. keeping lesions dry. c. preventing infection. d. using fabric softener to avoid rough cloth.
ANS: C The eczematous lesions of atopic dermatitis are intensely pruritic. Scratching can lead to new lesions and secondary infection. The infant's nails should be kept short and clean and have no sharp edges. In periods of irritability, these children tend to have a decreased appetite. The restriction of hyperallergenic foods, such as milk, dairy products, peanuts, and eggs, may make adequate nutrition a challenge with these children. Wet soaks and compresses are used to keep the lesions moist and minimize the pruritus. Fabric softener should be avoided because of the irritant effects of some of its components. PTS: 1 DIF: Cognitive Level: Apply REF: 1033 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
12. Herpes zoster is caused by the varicella virus and has an affinity for: a. sympathetic nerve fibers. b. parasympathetic nerve fibers. c. posterior root ganglia and posterior horn of the spinal cord. d. lateral and dorsal columns of the spinal cord.
ANS: C The herpes zoster virus has an affinity for posterior root ganglia, the posterior horn of the spinal cord, and skin. The zoster virus does not involve sympathetic or parasympathetic nerve fibers and the lateral and dorsal columns of the spinal cord. PTS: 1 DIF: Cognitive Level: Understand REF: 1019 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
30. Tretinoin (Retin-A) is a topical agent commonly used to treat acne. Nursing considerations with this drug should include: a. teaching to avoid use of sunscreen agents. b. applying generously to the skin. c. explaining that medication should not be applied until at least 20 to 30 minutes after washing. d. explaining that erythema and peeling are indications of toxicity.
ANS: C The medication should not be applied for at least 20 to 30 minutes after washing to decrease the burning sensation. The avoidance of sun and the use of sunscreen agents must be emphasized because sun exposure can result in severe sunburn. The agent should be applied sparingly to the skin. Erythema and peeling are common local manifestations. PTS: 1 DIF: Cognitive Level: Apply REF: 1036 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
43. Nitrous oxide is being administered to a child with extensive burn injuries. Which is the purpose of this medication? a. Promote healing. b. Prevent infection. c. Provide anesthesia. d. Improve urinary output.
ANS: C The use of short-acting anesthetic agents, such as propofol and nitrous oxide, has proven beneficial in eliminating procedural pain. Nitrous oxide is an anesthetic agent. PTS: 1 DIF: Cognitive Level: Understand REF: 1042 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
21. A father calls the clinic nurse because his 2-year-old child was bitten by a black widow spider. The nurse should advise which to the father? a. Apply warm compresses. b. Carefully scrape off stinger. c. Take child to emergency department. d. Apply a thin layer of corticosteroid cream.
ANS: C The venom of the black widow spider has a neurotoxic effect. The father should take the child to the emergency department for treatment with antivenin and muscle relaxants as needed. Warm compresses increase the circulation to the area and facilitate the spread of the venom. The black widow spider does not have a stinger. Corticosteroid cream will have no effect on the venom. PTS: 1 DIF: Cognitive Level: Apply REF: 1025 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
22. A mother calls the emergency department nurse because her child was stung by a scorpion. The nurse should recommend: a. administering an antihistamine. b. cleansing area with soap and water. c. keeping the child quiet and coming to the emergency department. d. removing the stinger and applying cool compresses.
ANS: C Venomous species of scorpions inject venom that contains hemolysins, endotheliolysins, and neurotoxins. The absorption of the venom is delayed by keeping the child quiet and the involved area in a dependent position. Antihistamines are not effective against scorpion venom. The wound will have intense local pain. Transport to the emergency department is indicated. PTS: 1 DIF: Cognitive Level: Analyze REF: 1026 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
51. A nurse is teaching a parent of an infant about treatment of seborrhea dermatitis (cradle cap). Which should the nurse include in the instructions? a. Shampoo every three days with a mild soap. b. The hair should be shampooed with a medicated shampoo. c. Shampoo every day with an antiseborrheic shampoo. d. The loosened crusts should not be removed with a fine-toothed comb.
ANS: C When seborrheic lesions are present, the treatment is directed at removing the crusts. Parents are taught the appropriate procedure to clean the scalp. Shampooing should be done daily with a mild soap or commercial baby shampoo; medicated shampoos are not necessary, but an antiseborrheic shampoo containing sulfur and salicylic acid may be used. Shampoo is applied to the scalp and allowed to remain on the scalp until the crusts soften. Then the scalp is thoroughly rinsed. A fine-tooth comb or a soft facial brush helps remove the loosened crusts from the strands of hair after shampooing. PTS: 1 DIF: Cognitive Level: Apply REF: 1035 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
35. Which explains physiologically the edema formation that occurs with burns? a. Vasoconstriction b. Decreased capillary permeability c. Increased capillary permeability d. Decreased hydrostatic pressure within capillaries
ANS: C With a major burn, an increase in capillary permeability occurs, allowing plasma proteins, fluids, and electrolytes to be lost. Maximal edema in a small wound occurs about 8 to 12 hours after injury. In larger injuries, the maximal edema may not occur until 18 to 24 hours. Vasoconstriction, decreased capillary permeability, and decreased hydrostatic pressure within capillaries are not physiologic mechanisms for edema formation in burn patients. PTS: 1 DIF: Cognitive Level: Analyze REF: 1040 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
2. The nurse is teaching nursing students about childhood skin lesions. Which is an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid? a. Cyst b. Papule c. Pustule d. Vesicle
ANS: D A vesicle is elevated, circumscribed, superficial, less than 1 cm in diameter, and filled with serous fluid. A cyst is elevated, circumscribed, palpable, encapsulated, and filled with liquid or semisolid material. A papule is elevated; palpable; firm; circumscribed; less than 1 cm in diameter; and brown, red, pink, tan, or bluish red. A pustule is elevated, superficial, and similar to a vesicle but filled with purulent fluid.
28. Atopic dermatitis (eczema) in the infant is: a. easily cured. b. worse in humid climates. c. associated with upper respiratory tract infections. d. associated with allergy with a hereditary tendency.
ANS: D Atopic dermatitis is a type of pruritic eczema that usually begins during infancy and is associated with allergy with a hereditary tendency. Atopic dermatitis can be controlled but not cured. Manifestations of the disease are worse when environmental humidity is lower. Atopic dermatitis is not associated with respiratory tract infections. PTS: 1 DIF: Cognitive Level: Understand REF: 1032 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
37. After the acute stage and during the healing process, the primary complication from burn injury is: a. asphyxia. b. shock. c. renal shutdown. d. infection.
ANS: D During the healing phase, local infection and sepsis are the primary complications. Renal shutdown is not a complication of the burn injury, but may be a result of the profound shock. PTS: 1 DIF: Cognitive Level: Apply REF: 1040 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
10. The nurse should expect to assess which causative agent in a child with warts? a. Bacteria b. Fungus c. Parasite d. Virus
ANS: D Human warts are caused by the human papillomavirus. Infection with bacteria, fungus, and parasites does not result in warts. PTS: 1 DIF: Cognitive Level: Understand REF: 1019 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
38. An adolescent girl is cooking on a gas stove when her bathrobe catches fire. Her father smothers the flames with a rug and calls an ambulance. She has sustained major burns over much of her body. Which is important in her immediate care? a. Wrap her in a blanket until help arrives. b. Encourage her to drink clear liquids. c. Place her in a tub of cool water. d. Remove her burned clothing and jewelry.
ANS: D In major burns, burned clothing should be removed to avoid further damage from smoldering fabric and hot beads of melted synthetic materials. Jewelry is also removed to eliminate the transfer of heat from the metal and constriction resulting from edema formation. The burns should be covered, not wrapped with a clean cloth. A blanket can be used initially to stop the burning process. Fluids should not be given by mouth to avoid aspiration and water intoxication. The child should be kept warm. Placing her in a tub of cool water will exacerbate heat loss. PTS: 1 DIF: Cognitive Level: Apply REF: 1041 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
39. A young child has sustained a minor burn to the foot. Which is recommended for treatment of a minor burn? a. Apply ice to foot. b. Apply cortisone ointment. c. Apply an occlusive dressing. d. Cleanse the wound with a mild soap and tepid water.
ANS: D In minor burns, the best method of treatment is to cleanse the wound with a mild soap and tepid water. Ice is not recommended. Most practitioners favor covering the wound with an antimicrobial ointment (not cortisone) to reduce the risk of infection and to provide some form of pain relief. The dressing is not occlusive but consists of nonadherent fine-mesh gauze placed over the ointment and a light wrap of gauze dressing that avoids interference with movement. This helps keep the wound clean and protects it from trauma. PTS: 1 DIF: Cognitive Level: Apply REF: 1041 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
4. A school-age child falls on the playground and has a small laceration on the forearm. The school nurse should do which to cleanse the wound? a. Slowly pour hydrogen peroxide over wound. b. Soak arm in warm water and soap for at least 30 minutes. c. Gently cleanse with sterile pad and a nonstinging povidone-iodine solution. d. Wash wound gently with mild soap and water for several minutes.
ANS: D Lacerations should be washed gently with mild soap and water or normal saline. A sterile pad is not necessary, and hydrogen peroxide and povidone-iodine should not be used because they have a cytotoxic effect on healthy cells and minimal effect on controlling infection. Soaking the arm will not effectively clean the wound. PTS: 1 DIF: Cognitive Level: Apply REF: 1015 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
52. The nurse is teaching parents of toddlers about animal safety. Which should be included in the teaching session? a. Petting dogs in the neighborhood should be encouraged to prevent fear of dogs. b. The toddler is safe to approach an animal if the animal is chained. c. It is permissible for your toddler to feed treats to a dog. d. Teach your toddler not to disturb an animal that is eating.
ANS: D Parents should be taught that toddlers should not disturb an animal that is eating, sleeping or caring for young puppies or kittens. The child should avoid all strange animals and not be encouraged to pet dogs in the neighborhood. The child should never approach a strange dog that is confined or restrained. The inexperienced child should not feed a dog (if the child pulls back when the animal moves to take the food, this can frighten and startle the animal). PTS: 1 DIF: Cognitive Level: Apply REF: 1030 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
16. Parents tell the nurse that their child keeps scratching the areas where he has poison ivy. The nurse's response should be based on which knowledge? a. Poison ivy does not itch and needs further investigation. b. Scratching the lesions will not cause a problem. c. Scratching the lesions will cause the poison ivy to spread. d. Scratching the lesions may cause them to become secondarily infected.
ANS: D Poison ivy is a contact dermatitis that results from exposure to the oil urushiol in the plant. Every effort is made to prevent the child from scratching because the lesions can become secondarily infected. The poison ivy produces localized, streaked or spotty, oozing, and painful impetiginous lesions. Itching is a common response. Scratching the lesions can result in secondary infections. The lesions do not spread by contact with the blister serum or by scratching. PTS: 1 DIF: Cognitive Level: Apply REF: 1022 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
27. Which prescribed treatment should the nurse plan to implement for a child with psoriasis? a. Antihistamines b. Oral antibiotics c. Topical application of calamine lotion d. Tar and exposure to sunlight and ultraviolet light
ANS: D Psoriasis is treated with tar preparations and exposure to ultraviolet B light or natural sunlight. Antihistamines, oral antibiotics, and topical application of calamine lotion are not effective in psoriasis. PTS: 1 DIF: Cognitive Level: Apply REF: 1031 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
8. Cellulitis is often caused by: a. herpes zoster. b. Candida albicans. c. human papillomavirus. d. Streptococcus or Staphylococcus organisms.
ANS: D Streptococci, staphylococci, and Haemophilus influenzae are the organisms usually responsible for cellulitis. Herpes zoster is the virus associated with varicella and shingles. C. albicans is associated with candidiasis, or thrush. Human papillomavirus is associated with various types of human warts. PTS: 1 DIF: Cognitive Level: Remember REF: 1018 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
41. A parent of a child with major burns asks the nurse why a high-calorie and high-protein diet is prescribed. Which response should the nurse make? a. The diet promotes growth. b. The diet will improve appetite. c. The diet will diminish risks of stress-induced hyperglycemia. d. The diet will avoid protein breakdown.
ANS: D The diet must provide sufficient calories to meet the increased metabolic needs and enough protein to avoid protein breakdown. Healing, not growth is the primary consideration. Many children have poor appetites, and supplementation will be necessary. Hypoglycemia, not hyperglycemia, can occur from the stress of burn injury because the liver glycogen stores are rapidly depleted. PTS: 1 DIF: Cognitive Level: Apply REF: 1042 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
50. The family of a 4-month-old infant will be vacationing at the beach. Which should the nurse teach the family about exposure of the infant to the sun? a. Use sun block on the infant's nose and ear tips. b. Use topical sunscreen product with a sun protective factor of 15. c. The infant can be exposed to the sun for 15-minute increments. d. Keep the infant in total shade at all times.
ANS: D The infant should be kept out of the sun or be physically shaded from it. Fabric with a tight weave, such as cotton, offers good protection. Infants should be covered with clothing or in the shade to prevent sun damage on the delicate skin at all times. The blocker can protect the nose and ear tips, but none of the infant's skin should be exposed. Sunscreens should not be used extensively on infants younger than 6 months. PTS: 1 DIF: Cognitive Level: Apply REF: 1048 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
19. The nurse is talking to the parents of a child with pediculosis capitis. Which should the nurse include when explaining how to manage pediculosis capitis? a. "You will need to cut the hair shorter if infestation and nits are severe." b. "You can distinguish viable from nonviable nits, and remove all viable ones." c. "You can wash all nits out of hair with a regular shampoo." d. "You will need to remove nits with an extra-fine tooth comb or tweezers."
ANS: D Treatment consists of the application of pediculicide and manual removal of nit cases. An extra-fine tooth comb facilitates manual removal. Parents should be cautioned against cutting the child's hair short; lice infest short hair as well as long. It increases the child's distress and serves as a continual reminder to peers who are prone to tease children with a different appearance. It is not possible to differentiate between viable and nonviable eggs. Regular shampoo is not effective; a pediculicide is necessary. PTS: 1 DIF: Cognitive Level: Apply REF: 1027 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential