Chapter 52 - Integumentary Dysfunction

A child steps on a nail and sustains a puncture wound in the foot. What 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.

Lymphangitis ("streaking") is frequently seen in which condition? a. Cellulitis b. Folliculitis c. Impetigo contagiosa d. Staphylococcal scalded skin

ANS: A Lymphangitis, known as streaking, is frequently seen in cellulitis. If present, hospitalization is usually required for parenteral antibiotic. Lymphangitis is not associated with folliculitis, impetigo, or staphylococcal scalded skin.

A child with extensive burns requires debridement. What is the priority of this procedure? a. To promote healing b. To prevent bleeding c. To maintain the airway d. To restore fluid balance

ANS: A Partial-thickness burns require debridement of devitalized tissue to promote healing. The procedure is very painful and requires analgesia and sedation beforehand. Preventing bleeding, maintaining the airway, and restoring fluid balance are not goals of debridement.

Impetigo ordinarily results in which outcome? a. No scarring b. Pigmented spots c. Slightly depressed scars d. Atrophic white scars

ANS: A Impetigo tends to heal without scarring unless a secondary infection occurs.

What is 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.

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 Accutane (isotretinoin) is reserved for severe cystic acne that has not responded to other treatments. Accutane has teratogenic effects and should never be used when there is a possibility of pregnancy. No correlation exists between foods and acne. Frequent washing with antibacterial soap is not a recommended therapy for acne.

The treatment of a child who has just been stung by a bee or wasp should include which intervention? a. Cool compresses b. Warm compresses c. Antibiotic cream d. Corticosteroid cream

ANS: A Bee or wasp stings are initially treated by carefully removing the stinger, cleansing the site 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 to address pain and swelling. Warm compresses are to be 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.

Which is an effective strategy to reduce the stress of burn dressing procedures? a. Give the child as many choices as possible. b. Reassure the child that dressing changes are not painful. c. Explain to the child why analgesics cannot be used. d. Encourage the child to master stress with controlled passivity.

ANS: A Children who have an understanding of the procedure and some perceived control demonstrate less anxious behaviour. They respond well to participating in decisions and should be given as many choices as possible. The dressing-change procedure is very painful and stressful, so the child should not be misinformed about it. Analgesia and sedation can and should be used. Encouraging the child to master stress with controlled passivity is not a positive coping strategy.

A child experiences frostbite on the fingers after prolonged exposure to the cold. What intervention should the nurse use first? a. Rapidly rewarm the fingers by placing them in warm water. b. Place the hand in cool water. c. Slowly rewarm the fingers by wrapping them in a warm cloth. d. Use an ice pack to keep fingers cold until medical intervention is possible.

ANS: A Rapid rewarming is recommended by immersing the affected part in well-agitated water at 37.8°C to 42.2°C and results in less tissue necrosis than slow thawing. The frostbitten area should be rewarmed as soon as possible to avoid further tissue damage.

What is the most immediate threat to life in children with thermal injuries? 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 and sepsis are the primary complications.

Where do the lesions of atopic dermatitis most commonly occur on the infant? a. Cheeks b. Buttocks c. Eyes d. Back

ANS: A The lesions of atopic dermatitis are generalized on the infant. They are most commonly on the cheeks, scalp, trunk, and extensor surfaces of the extremities. Lesions do not generally occur on the buttocks and back.

The nurse is examining a 12-month-old boy who was brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with satellite lesions that cross the inguinal folds. What is the most likely cause? a. Impetigo b. Candida albicans c. Urine and feces d. Infrequent diapering

ANS: B Candida 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.

A child is admitted with extensive burns. The nurse notes that there are burns on the child's lips and singed nasal hairs. What should the nurse suspect based on these assessment findings? 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 and electrical burns and those associated with hot-water scalds do not have singed nasal hair.

A toddler sustains a minor burn on the hand from hot coffee. What is the first action to take in treating this burn? a. Apply ice to burned area. b. Hold the burned area under cool running water. c. Break any blisters with a sterile needle. d. Clean the wound with soap and warm water.

ANS: B For 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 a generally accepted therapy unless the injury is from a chemical substance. Cooling is necessary to stop the burning process.

What is the most 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 changing the dressing. c. If dressings adhere to the wound, soak in hot water before removal. d. Apply the 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 too tight to impair circulation or limit motion.

Which is the cause of ringworm that is frequently found in schoolchildren? 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. It is a superficial infection that lives on, not in, the skin. Viral and bacterial infections are not causative organisms for ringworm. Ringworm is not an allergic response.

What kind of bite causes Rocky Mountain spotted fever? a. A flea b. A tick c. A mosquito d. A 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, mosquitos, mice, and rats do not transmit Rocky Mountain spotted fever.

The nurse is teaching a class about preventing diaper rash in newborns to a group of new parents. Which statement made by one parent indicates he has a correct understanding of the teaching? a. "I should wash my infant's buttocks with soap and water every time I change the diaper." b. "I will wash my infant with a mild soap and water and dry her thoroughly after a bowel movement." 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 The diaper should be changed as soon as it becomes soiled. Stool should be wiped gently from skin with water and mild soap. Overwashing the skin should be avoided, especially with perfumed soaps or commercial wipes, which may be irritating. 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.

The nurse is talking to the parent of an infant with severe atopic dermatitis. What should the nurse reinforce for the parent? a. "You can use warm, wet compresses to relieve discomfort." b. "You should apply an emollient to the skin immediately after a bath." c. "You should bathe your baby in a bubble bath two times a day." d. "You can try a fabric softener in the laundry to avoid rough cloth."

ANS: B The eczematous lesions of atopic dermatitis are intensely pruritic. Scratching can lead to new lesions and secondary infection; an antihistamine can be used to reduce inflammation. Keeping the skin hydrated is the goal of atopic dermatitis treatment. Applying an emollient immediately after a bath (within 3 minutes) helps to trap moisture and prevent moisture loss. Using warm compresses to relieve discomfort, bathing the baby in a bubble bath, and using fabric softener are not appropriate suggestions for this condition.

What is the primary treatment for warts? a. Vaccination b. Local destruction c. Corticosteroids d. Specific antibiotic therapy

ANS: B Topical treatments include chemical cautery, which is especially useful for the treatment of warts. Local destructive therapy is individualized according to the location, type, and number of warts. Surgical removal, electrocautery, curettage, cryotherapy, caustic solutions, x-ray treatment, and laser therapies are used. Vaccination is prophylaxis for warts and is not a treatment. Corticosteroids and specific antibiotic therapy are not effective in the treatment of warts.

Biological dressings are applied to a child with partial-thickness burns on both legs. Which nursing action is related to this procedure? a. Observe wounds for bleeding. b. Observe wounds for signs of infection. c. Monitor the child closely for signs of shock. d. Splint the child's legs to prevent movement.

ANS: B When applied early to a superficial partial-thickness injury, biological dressings stimulate epithelial growth and faster wound healing. If the dressing covers areas of heavy microbial contamination, infection occurs beneath it. In the case of partial-thickness burns, such infection may convert the wound to a full-thickness injury. Infection is the primary concern when biological dressings are used.

What is one important nursing consideration 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. Practise good hand hygiene 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 goal related to bacterial skin infections such as impetigo contagiosa is to prevent the spread of the infection and complications. This is done using thorough hand hygiene 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 in certain disease states such as tinea capitis.

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.

A mother calls the emergency department nurse because her child was bit by a brown recluse spider. What should the nurse recommend? a. Administer antihistamine. b. Cleanse the wound with soap and water. c. Keep the child quiet and come to the emergency department. d. Remove the stinger and apply cool compresses.

ANS: C Brown recluse spiders inject venom deadly enough to require emergency treatment. The absorption of the venom is delayed by keeping the child quiet and the involved area below the level of the child's heart if at all possible. Antihistamines are not effective against spider venom. The wound will produce intense local pain and erythema.

What is one of the first signs of overwhelming sepsis in a child with burn injuries? a. Seizures b. Bradycardia c. Decreased level of consciousness d. Decreased blood pressure

ANS: C Decreasing level of consciousness in a 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.

Fentanyl and midazolam (Versed) are given before debridement of a child's burn wounds. What is the purpose of these drugs? a. To promote healing b. To prevent infection c. To provide pain relief d. To limit the amount of debridement that will be necessary

ANS: C Fentanyl and midazolam provide excellent intravenous sedation and analgesia to control procedural pain in children with burns. They do not promote healing or prevent infection, nor do they limit the amount of debridement needed.

What should the nurse know about Lyme disease? a. It is difficult to prevent. b. It is easily treated with oral antibiotics in stages 1, 2, and 3. c. It is caused by a spirochete that enters the skin through a tick bite. d. It is 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 called erythema migrans. Tick bites may be avoided by entering tick-infested areas with caution. Light-coloured clothing should be worn so that ticks can be identified easily. Long-sleeve shirts and long pants tucked into socks should be worn. Early treatment of the erythema migrans (stage 1) can prevent the development of Lyme disease. It is caused by a spirochete, not mycotic spore.

What does treatment for herpes simplex virus (types 1 or 2) include? 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 and antibiotics are not effective for viral infections. Griseofulvin is an antifungal agent and is not effective for viral infections.

What is the primary clinical manifestation of scabies? 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. In a previously sensitized person, the response occurs within 48 hours. Edema, redness, and maceration are not observed in scabies.

A father calls the clinic nurse because his 2-year-old child was bitten by a black widow spider. What should the nurse advise the father to do? a. Apply warm compresses. b. Carefully scrape off the stinger. c. Take the child to the emergency department. d. Apply a thin layer of corticosteroid cream.

ANS: C The black widow spider has venom that is toxic enough to be harmful. The father should take the child to the emergency department for immediate treatment. Warm compresses increase circulation to the area and facilitate the spread of the venom. The black widow spider does not have a stinger. Corticosteroid cream has no effect on venom.

Which is an appropriate nursing intervention when caring for an infant with atopic dermatitis? a. Feed a variety of foods. b. Keep lesions dry. c. Prevent infection. d. Use 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. During 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.

Herpes zoster is caused by the varicella virus and has an affinity for which structure(s)? a. Sympathetic nerve fibres b. Parasympathetic nerve fibres c. Posterior root ganglia and the 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, and does not involve sympathetic or parasympathetic nerve fibres, nor lateral and dorsal columns of the spinal cord.

Tretinoin (Retin-A) is a topical agent commonly used to treat acne. What advice should the nurse provide to patients prescribed this drug? a. Avoid using sunscreen agents. b. Use cosmetics with lanolin and petrolatum. c. Explain that medication should not be applied until at least 20 to 30 minutes after washing. d. Explain 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. Avoiding the sun and using sunscreen agents must be emphasized because sun exposure can result in severe sunburn. Cosmetics with lanolin, petrolatum, vegetable oil, lauryl alcohol, butyl stearate, and oleic acid can increase comedone production. Erythema and peeling are common local manifestations.

Which is a physiological explanation of 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 after injury. Vasoconstriction, decreased capillary permeability, and decreased hydrostatic pressure within capillaries are not physiological mechanisms for edema formation in burn patients.

What is often a cause of cellulitis? a. Herpes zoster b. Candida albicans c. Human papillomavirus d. Streptococcus or Staphylococcus organisms

ANS: D Streptococcus, Staphylococcus, and Haemophilus influenzae are the organisms usually responsible for cellulitis. Herpes zoster is the virus associated with varicella and shingles. Candida albicans is associated with candidiasis or thrush. Human papillomavirus is associated with various types of human warts.

A young boy's mother tells the nurse that he keeps scratching the areas where he has poison ivy. How should the nurse respond? 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 must be 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. The lesions do not spread by contact with the blister serum or by scratching.

Which statement is true regarding atopic dermatitis (eczema) in the infant? a. It is easily cured. b. It is worse in humid climates. c. It is associated with upper respiratory tract infections. d. It is 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. It can be controlled but not cured. Manifestations of the disease are worse when environmental humidity is lower. Atopic dermatitis is not associated with respiratory infections.

After the acute stage and during the healing process, what is the primary complication from a burn injury? a. Asphyxia b. Shock c. Renal shutdown d. Infection

ANS: D During the healing phase, local infection and sepsis are the primary complications. Respiratory problems, chiefly airway compromise, are the primary complications during the acute stage of a burn injury.

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. What is most 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 jewellery.

ANS: D For major burns, burned clothing should be removed to avoid further damage from smouldering fabric and hot beads of melted synthetic materials. Jewellery 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 further exacerbate heat loss.

What causes warts? a. Bacteria b. Fungus c. Parasite d. Virus

ANS: D Human warts are caused by the human papillomavirus. Infection with bacteria, fungus, and parasitic organisms does not result in warts.

A child falls on the playground and has a small laceration on the forearm. What should the school nurse do 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 non stinging povidone-iodine solution. d. Wash wound with mild soap and water or saline for several minutes.

ANS: D Lacerations should be washed 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 does not effectively clean the wound.

Why is a high-protein diet recommended for a child with major burns? a. It promotes growth. b. It improves appetite. c. It diminishes the risks of stress-induced hyperglycemia. d. It helps prevent 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 a burn injury because liver glycogen stores are rapidly depleted.

The family of a 4-month-old infant will be vacationing at the beach. What is the best recommendation about sun exposure for this family? a. Use sunblock on the infant's nose and ear tips. b. Use a topical sunscreen 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 physically shaded from it. Fabric with a tight weave such as cotton offers good protection. Infants should be covered with clothing or kept in the shade at all times to prevent sun damage to their delicate skin. The sunblock 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.