Chapter 45: Tissue Integrity/Integumentary Disorder NCLEX style

The nurse is teaching the parents of a 6-year-old who has sustained a large laceration about providing care to the wound at home. The nurse determines that the parents need additional teaching when they state:

"We need to keep the wound tightly bandaged for at least 3 days."

The nurse has completed client teaching with a 16-year-old female who has been prescribed isotretinoin for cystic acne. Which statements indicate learning has occurred? Select all that apply.

- "If I am sexually active I need to let my doctor know." - "This is not a drug to be used for all forms of acne. My sister has minor acne so I told her this wasn't for her." - "It's important I get my CBC blood test when my doctor orders it."

The nurse is caring for a child admitted with partial thickness burns. What is most characteristic of this type of burn?

Blisters appear

The nurse is caring for a child with a partial-thickness burn. What assessment findings would the nurse expect to observe?

Edema with wet blistering skin

What accurately depicts the hemodynamic changes that occur in the body within the first 24 to 48 hours after a burn?

Hematocrit and WBC counts elevate

A nurse 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. Which should the nurse ask the mother?

"Does she wear sleepers with metal snaps?"

The nurse admits a 10-year-old who has just eaten lobster and has hives over much of the body. In collecting data regarding this child, which question should the nurse ask the caregiver first?

"Has the child ever eaten shellfish before now?"

The nurse is discussing acne vulgaris with a group of adolescents. The teenagers make the following statements regarding the topic. Which statement is the most accurate regarding acne vulgaris?

"Sometimes I get acne when I use my sister's makeup."

The nurse is reviewing the integumentary system during a presentation to a group of nurses. Which statement made by the nurse is the most accurate regarding the integumentary system?

"The largest organ of the body helps regulate body temperature."

A pediatric client was brought to the emergency department by the parents after experiencing extensive urticaria following consumption of a seafood dinner. Upon discharge from the facility the nurse provided client teaching. Which statement by the parents indicate learning occurred?

"We need to get our child a medical alert bracelet as soon as possible in case this happens again."

A nurse 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 should bathe our child in hot water, twice a day."

A newborn has a generalized rash on the skin, which the nurse identifies as erythema toxicum neonatorum. Which informaiton would the nurse include when explaining the condition to the newborn's parent?

"What you see on your newborn's skin is erythema toxicum neonatorum. It is a common newborn skin condition that typically resolves on its own in about 1 week. There is nothing special you will need to do for this."

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."

The student nurse gives a presentation on the dangers of sun exposure to clients at a community health center. Which statements by the attendees demonstrate that knowledge was gained from the presentation?

- A 17-year-old states that she stopped using the tanning bed after attending the presentation - A 15-year-old states that she always uses sunscreen because she "doesn't want to get skin cancer like my mother did." - An adolescent client states that it "scares me to think that my cells are changing when I get a sunburn."

An adolescent is to receive topical retinoid therapy for his moderately severe acne. The nurse would instruct the adolescent about which adverse effects? Select all that apply.

- Burning - Photosensitivity - Dryness

A nurse is caring for a child with a wasp sting. Which nursing intervention is priority?

Administer diphenhydramine per protocol

The camp nurse is caring for a child who was bitten on the leg by a dangerous spider. The child is being taken to a care provider. What is the most appropriate action for the nurse to do with this child?

Apply ice to the affected area.

The nurse is speaking with the mother of a child diagnosed with contact dermatitis from poison ivy. Which statement by the mother indicates a need for further education?

As long as he takes a shower as soon as he gets inside, he shouldn't get this again."

The nurse is caring for a child with urticaria (hives). What is the priority action?

Assessing the child's airway and breathing and noting any wheezing or stridor

In working with infants diagnosed with atopic dermatitis, the nurse anticipates that when these children are older they will likely have a tendency to have which disorder?

Asthma

The nurse is collecting data from a 14-year-old female and her mother who have come to the clinic for a check-up. The child's mother reports the teen has had hives intermittently for the past two months. What is the priority action for this client?

Determine the underlying cause.

The nurse is assessing a child who pulled a boiling pot of soup off of the stove top. The child reports pain at a 9 on a scale of 0 to 10. The burn is red and edematous, and also shows areas of charred skin. The nurse is aware that these signs and symptoms are indicative of what kind of burn?

Full-thickness

The nurse is caring for a pediatric client in the emergency department with moderate frostbite of an extremity. Which is the most beneficial nursing intervention for this client?

Immerse the affected part in 104°F (40°C) water for 15 to 30 minutes.

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

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

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.

The nurse caring for a child with a skin allergy recognizes that the highest priority in the treatment for skin allergies is aimed at:

Reducing swelling and relieving itching.

A young child has just been admitted to the emergency department with a burn that encompasses the dermis and the underlying dermis. From which type of burn does this child suffer?

Second-degree burn

The nurse is caring for a 7-year-old with burns. Which finding would be highly suggestive of a child abuse-induced burn?

Stocking-glove pattern on hands or feet

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

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

The nurse is caring for a child with a severe burn. The treatment for this child during the first 48 hours will be most likely be related to:

hypovolemic shock.

The school nurse has completed an educational program on first aid practices in the home. Which statement about burn care by a participant would indicate a need for further education?

"I guess my mom was right, she always put ice on our burns when we were kids."

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 should be certain to use fabric softener in the care of the infant's clothes."

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.

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?

Acute pain related to thermal injuries and procedures

A nurse is caring for a child with second and third degree burns over 15% of the body. The child reports severe itching in and around the burn sites. Which action would be most appropriate for the nurse to perform?

Administer diphenhydramine.

The client is scheduled to have potassium hydroxide testing performed. What will be needed to complete this test?

Skin scrapings

A teen experiencing contact dermatitis reports that he is experiencing pruritis. What recommendation may reduce this occurrence?

Take oatmeal baths.

A child is admitted to the acute care facility with a burn injury. The nurse would check the child's immunization status, specifically for which of the following?

Tetanus

The school nurse is leading a discussion with a group of adolescents on the various sexually transmitted infections (STIs). The nurse determines the session is successful when the students correctly choose which STIs as considered curable with proper treatment? Select all that apply.

- chlamydia - gonorrhea - trichomoniasis

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?

Community acquired MRSA