London ch 57
6) Which is the priority nursing diagnosis when planning care for an infant who is diagnosed with a severe case of oral thrush (Candida albicans)? 1. Ineffective Infant Feeding Pattern related to discomfort 2. Ineffective Breathing Pattern related to oral thrush 3. Activity Intolerance related to oral thrush 4. Ineffective Airway Clearance related to mucus
Answer: 1 Explanation: 1. An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt treatment is necessary so the infant can resume a normal feeding pattern. 2. Ineffective breathing pattern is not usually associated with oral thrush. An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt recognition and treatment are necessary so that a normal feeding pattern can be resumed. 3. Activity intolerance is not usually associated with oral thrush. An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt recognition and treatment are necessary so that a normal feeding pattern can be resumed. 4. Ineffective airway clearance is not usually associated with oral thrush. An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt recognition and treatment are necessary so that a normal feeding pattern can be resumed. Page Ref:1562
14) Which parental statement regarding preventative strategies for insect bites and stings indicate the need for further education? 1. "If my child wears bright colors and floral prints when outdoors, she will blend in with the surroundings, and the stinging insects will not sting her." 2. "We should remove any items with standing water from our yard and surrounding area to prevent mosquito reproduction." 3. "My child can use insect repellent containing DEET of 10% or less." 4. "My child should avoid heavy colognes, perfumes, and soaps so that insects are not attracted to them."
Answer: 1 Explanation: 1. Bright-colored clothing and floral prints attract the insects. White and light-colored clothing should be worn. This statement requires clarification. 2. Standing water is a breeding ground for mosquitoes. Rid yards of all bird baths, stagnant pools, and any standing water that mosquitoes could use for breeding. No clarification is needed. 3. DEET is an appropriate insect repellent and can be used in children. A concentration of 10% or less is recommended due to neurotoxic effects at greater concentrations. No clarification is needed. 4. Heavy colognes, perfumes, soaps, and detergents resemble flowers and plants and will attract the stinging insects. This statement is correct. Page Ref: 1588
1) Which is the most likely cause for a bright red perianal inflammation with scaly plaques and small papules noted by the nurse during the assessment of a 12-month-old infant? 1. Candida albicans (yeast) 2. Impetigo (staphylococcus) 3. Infrequent diapering 4. Urine and feces
Answer: 1 Explanation: 1. Candida albicans is frequently the underlying cause of severe diaper rash. When a primary or secondary infection with C. albicans occurs, the rash has bright red, scaly plaques with sharp margins. Small papules and pustules might be seen, along with satellite lesions. 2. Even though diaper dermatitis can be caused by impetigo, urine, feces, and infrequent diapering, the lesions and persistent characteristics are common for Candida infection. 3. Infrequent diapering, along with urine and feces, can cause diaper dermatitis, but the persistence and characteristics of the lesions are common for Candida infection. 4. Urine and feces can cause diaper dermatitis, but the persistence and characteristics of the lesions are common for Candida infection. Page Ref: 1558
10) Which is the priority nursing diagnosis during the acute phase of a third-degree circumferential burn of the right arm for a pediatric client? 1. Altered Tissue Perfusion, Risk for 2. Infection, Risk for 3. Impaired Physical Mobility 4. Altered Nutrition: Less than Body Requirements, Risk for
Answer: 1 Explanation: 1. Circumferential burns can restrict blood flow due to edema, resulting in tissue hypoxia. Altered Tissue Perfusion to the extremity is the greatest risk and therefore the priority diagnosis. 2. When the burn is circumferential, blood flow can become restricted due to edema and can result in tissue hypoxia; therefore, the priority diagnosis is Altered Tissue Perfusion, Risk for, to the extremity. Risk of infection would be a secondary priority in this case. 3. Impaired physical mobility is a secondary priority for the child with a circumferential burn. Edema to the area can result in restricted blood flow and tissue hypoxia, making the priority diagnosis Altered Tissue Perfusion, Risk for. 4. Infection, nutrition, and mobility would have secondary priority in this case. Page Ref: 1581-1582
20) Which is the priority nursing intervention for a 4-year-old client brought to the emergency department (ED) for treatment of frostbite? 1. Administer analgesics. 2. Immerse the hands in extremely warm water (120°F). 3. Do not remove clothing. 4. Place the extremity in a dependent position.
Answer: 1 Explanation: 1. Nursing interventions for frostbite include removing wet clothing, using mildly warm water (at 100 to 104°F) to warm the extremity, administering analgesics to decrease pain of the rewarming process, and raising the affected extremity to improve venous return. 2. Nursing interventions for frostbite include removing wet clothing, using mildly warm water (at 100 to 104°F) to warm the extremity, administering analgesics to decrease pain of the rewarming process, and raising the affected extremity to improve venous return. 3. Nursing interventions for frostbite include removing wet clothing, using mildly warm water (at 100 to 104°F) to warm the extremity, administering analgesics to decrease pain of the rewarming process, and raising the affected extremity to improve venous return. 4. Nursing interventions for frostbite include removing wet clothing, using mildly warm water (at 100 to 104°F) to warm the extremity, administering analgesics to decrease pain of the rewarming process, and raising the affected extremity to improve venous return. Page Ref: 1586-1587
7) Which parental statement indicates to the nurse accurate understanding regarding the care of their child with tinea capitis (ringworm of the scalp)? 1. "We will give the griseofulvin with milk or peanut butter." 2. "We're glad ringworm isn't transmitted from person to person." 3. "Once the lesion is gone, we can stop the griseofulvin." 4. "Well, at least we don't have to worry about the family cat getting the ringworm."
Answer: 1 Explanation: 1. Parents are advised to give oral griseofulvin with fatty foods such as milk or peanut butter to enhance absorption. 2. All members of the family and household pets should be assessed for fungal lesions because person-to-person transmission is common[B1] . 3. The medication must be used for the entire prescribed period, even if the lesions are gone. 4. Dogs and cats can develop the fungal lesions and be sources of spread of the organism. Page Ref: 1562 [B1]Erin--add "Animal-to-person transmission may also occur?"
9) Which should the nurse include in the plan of care for a child with a minor burn to enhance nutrition and healing? 1. Protein 2. Minerals 3. Carbohydrates 4. Fats
Answer: 1 Explanation: 1. Parents should be taught that management of a minor burn requires a high-calorie, high-protein diet. This is necessary to meet the increased nutritional requirements of healing. 2. A high-calorie, high-protein diet is required to meet the increased nutritional requirements for healing. 3. The family should be taught that a high-calorie, high-protein diet is best to meet the increased nutritional requirements for healing. 4. A high-calorie, high-protein diet is best to meet the increased nutritional requirements for healing. Page Ref: 1582
8) Which nursing action is accurate when applying a 5% permethrin lotion to a toddler with scabies? 1. Applying the lotion to the scalp, forehead, and everywhere below the chin 2. Applying the lotion only on the areas with evidence of activity 3. Applying the lotion only to the hands 4. Applying the lotion only to the scalp only
Answer: 1 Explanation: 1. Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down. The scabicide is also applied to the scalp and forehead of younger children, avoiding the rest of the face. 2. Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down, as well as the scalp and forehead. 3. Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down, including the scalp and forehead. 4. Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down, as well as the scalp and forehead. Page Ref: 1574
25) Which topics should be included in a teaching session with parents of school-age children to prevent frostbite? Select all that apply. 1. Dressing in layers 2. Having extra clothing available 3. Removing wet gloves immediately 4. Applying sunscreen twice per day 5. Wearing sunglasses while outside
Answer: 1, 2, 3 Explanation: 1. Dressing in layers is a topic the nurse should include in the teaching session with parents of school-age children to prevent frostbite. 2. Having extra clothing available is a topic the nurse should include in the teaching session with parents of school-age children to prevent frostbite. 3. Removing wet gloves immediately is a topic the nurse should include in the teaching session with parents of school-age children to prevent frostbite. 4. Application of sunscreen is an appropriate topic to prevent sunburn, not frostbite. 5. Wearing sunglasses while outside is an appropriate topic to prevent sunburn, not frostbite. Page Ref: 1586-1587
22) Which pain interventions should the nurse include in the plan of care for a pediatric client who suffered a full-thickness burn injury? Select all that apply. 1. Using an age-appropriate assessment scale 2. Covering the affected skin as much as possible 3. Providing analgesics prior to wound care 4. Keeping the skin as clean and dry as possible 5. Clipping hair around the wound
Answer: 1, 2, 3 Explanation: 1. Pain assessment with an age-appropriate scale is an appropriate intervention for the nurse to include in the plan of care for a client with a full-thickness burn injury. 2. Covering the affected area to prevent temperature changes and air movement is an appropriate intervention for the nurse to include in the plan of care for a client with a full-thickness burn injury. 3. Analgesics administration prior to wound care is an appropriate intervention for the nurse to include in the plan of care for a client with a full-thickness burn injury. 4. Keeping the skin as clean and dry as possible is an appropriate intervention to decrease infection, not pain. 5. Clipping hair around the wound is an appropriate intervention to decrease infection, not pain. Page Ref: 1581-1582
24) Which topics should be included in a teaching session with parents of school-age children to prevent sunburn? Select all that apply. 1. Playing in the shade 2. Wearing a hat while outdoors 3. Restricting outside activities between 10 a.m. and 2 p.m. 4. Using sunscreen with an SPF of 30 or higher 5. Avoiding sunglasses
Answer: 1, 2, 4 Explanation: 1. The nurse should recommend that school-age children play in the shade while outdoors to decrease the risk for sunburn. 2. The nurse should recommend that school-age children wear a hat while outdoors to decrease the risk for sunburn. 3. Outdoor activities should be restricted between 10 a.m. and 4 p.m. to decrease the risk for sunburn. 4. The nurse should recommend that school-age children use sunscreen with an SPF of 30 or higher to decrease the risk for sunburn. 5. Sunglasses should be encouraged, not discouraged, to decrease the risk for sunburn around the eyes. Page Ref: 1586
19) Which preventative strategies for tinea pedis, a fungal infection, also known as athlete's foot, should the nurse include in a teaching session for an adolescent client? Select all that apply. 1. Wear 100% white cotton socks, changed twice a day. 2. Use talc on feet daily. 3. Use an over-the-counter corticosteroid cream to treat the area. 4. Wear foot covers such as flip flops in the locker room and shower. 5. Apply heat to the area twice a day.
Answer: 1, 2, 4 Explanation: 1. The socks will wick moisture away from the feet to promote healing. 2. This process will help keep the feet dry. 3. Corticosteroids will not destroy the organism. An antifungal medication is required. 4. This will reduce the spread of the organism among team members. 5. Heat will not treat the problem. Antifungal medications are required. Page Ref: 1563
4) A child had an appendectomy and was discharged home at 48 hours postoperative. A week later, the child is readmitted for delayed wound healing. Which causes of delayed wound healing will the nurse review prior to assessing the child? Select all that apply. 1. Infection 2. Predisposing chronic condition, such as diabetes 3. Hypervolemia 4. Inadequate nutrition 5. Hypoxemia
Answer: 1, 2, 4, 5 Explanation: 1. Infection can affect healing and cause excessive scarring. 2. Conditions such as diabetes affect circulating blood volume and are known to affect healing. 3. Hypovolemia, not hypervolemia, would inhibit inflammation due to low circulating blood volume. 4. Poor nutrition without proper protein and calorie intake will affect healing. 5. Hypoxemia makes tissues susceptible to infection due to insufficient oxygenation. Page Ref: 1590
16) Which skin conditions should the nurse identify as having a genetic or inherited component during a presentation to the staff nurses who work in the integument clinic? Select all that apply. 1. Atopic dermatitis 2. Seborrheic dermatitis 3. Epidermolysis bullosa 4. Molluscum contagiosum 5.Psoriasis
Answer: 1, 3, 5 Explanation: 1. Atopic dermatitis is an allergic skin disorder. Allergies have an inherited component. 2. Seborrheic dermatitis is thought to be an overgrowth of yeast and is influenced by hormones. It is not inherited. 3. Epidermolysis bullosa is inherited either as autosomal dominant or autosomal recessive depending on type. 4. Molluscum is caused by a poxvirus and is transmitted person to person. 5. Psoriasis is usually seen in clients with a family history. A multifactorial inheritance is suspected. Page Ref:1567; 1571
13) Which is the priority nursing action when providing care to a child who is bitten by a snake? 1. Measuring the circumference of the extremity twice per hour 2. Monitoring respiratory status 3. Assessing vital signs 4. Evaluating response to pain medication
Answer: 2 Explanation: 1. In order to track progression in swelling and response to treatment, the extremity with the bite is measured every 20 to 30 minutes. However, this does not take priority over airway, breathing, and circulation. 2. Emergency intervention for airway, breathing, and circulation takes priority and has a high probability of occurrence. 3. Vital signs and neurovascular status of the distal extremities should be monitored but do not take priority over airway, breathing, and circulation. 4. Pain medication will need to be given and the response to the treatment monitored; however, this should not take priority over airway, breathing, and circulation. Page Ref: 1588
12) The nurse explains to the parents of a child with a severe burn that wearing an elastic pressure garment (Jobst stocking) during the rehabilitative stage can help prevent which complication? 1. Pain 2. Hypertrophic scarring 3. Poor circulation 4. Formation of thrombus in the burn area
Answer: 2 Explanation: 1. The Jobst stockings, or pressure garments, do not prevent pain. They are used to prevent development of hypertrophic scarring and contractures. 2. During the rehabilitation stage, Jobst stockings, or pressure garments, are used to reduce development of hypertrophic scarring and contractures. 3. The Jobst pressure garments are used to prevent or minimize the development of hypertrophic scarring and contractures. 4. The elastic pressure garments are used to prevent development of hypertrophic scarring and contractures. They do not prevent the formation of thrombus in the burn area. Page Ref: 1580
18) Which clinical therapy should the nurse anticipate when planning care for a toddler-age client who is admitted to the hospital unit with cellulitis of the neck? 1. Topical antibiotics 2. Intravenous antibiotics 3. Incision and drainage 4. Oral corticosteroids
Answer: 2 Explanation: 1. This is an infection of the deeper tissues including the dermis and supporting connective tissues. Topical antibiotics will not reach the infection. 2. This infection usually requires parenteral antibiotics. 3. The infection is not consolidated into an abscess, so an incision and drainage would not be performed. 4. Corticosteroids are anti-inflammatories and would not be used to treat this infection. Page Ref: 1560-1561
17) Which adolescent statement regarding skin care and acne prevention would indicate the need for further education by the nurse? 1. "I shouldn't squeeze my blackheads or pimples." 2. "I need to watch my diet and cut out all chocolates." 3. "I should avoid applying drying materials, such as astringents, to my face" 4. "I should wash my hands frequently and avoid touching my face."
Answer: 2 Explanation: 1. This practice can introduce organisms into the lesions and should be avoided. This statement needs no clarification. 2. There has been no research that connects diet to acne. A healthy diet with protein is recommended, but chocolate does not have to be excluded. This statement needs to be clarified. 3. This statement is accurate and needs no clarification. 4. This is an important means of reducing facial irritation. Page Ref:1569-1571
3) The 10-year-old child is admitted to the hospital following an accident at school that resulted in a puncture wound of the abdomen. Two days after the injury, the child continues in the inflammation phase of healing. What would the nurse expect to see while changing the child's dressing and assessing the wound? 1. The wound is contracting, and the edges are growing together. 2. A blood clot has formed, sealing the wound. 3. Epithelial cells are growing into the wound. 4. The wound is pale and weepy.
Answer: 2 Explanation: 1. Wound contraction and inward movement of the wound edge occur during the reconstruction phase of wound healing. 2. Clot formation to seal the wound with fibrin and trapped cells and platelets occurs during the inflammation phase of wound healing, in the first 3 to 5 days. 3. Epithelial cells growing into the wound occurs in the reconstruction phase of wound healing. 4. During the initial phase of healing, there is increased blood flow, giving the area an "inflamed" appearance. Page Ref: 1587
15) Which discharge instruction is appropriate for an adolescent client who is a paraplegic due to a motor vehicle accident, in order to prevent decubitus ulcer formation on the buttock? 1. Contract the muscles 5 times every 2 hours. 2. Increase fat in the diet to provide a protective coating over the bony prominences. 3. Do wheelchair push-ups every 15 to 30 minutes. 4. Avoid use of sheepskin, as it prevents air from reaching the area.
Answer: 3 Explanation: 1. The child is a paraplegic and therefore unable to contract the buttock muscles. 2. Extra weight will add to pressure on the bony prominences and should be avoided. 3. Lifting the buttocks with the arms can help with blood flow to the buttocks and reduce the risk of breakdown. 4. Sheepskin can reduce pressure on the buttocks; it is one of many pressure reducing materials available. Page Ref: 1557
21) Which adolescent statements indicate the need for further education related to the prevention and treatment of acne? Select all that apply. 1. "I should wash my face each day with an approved cleanser." 2. "I should wash my hands frequently and avoid touching my face." 3. "I should stay away from greasy foods, such as pizza." 4. "I should shampoo my hair only once per week." 5. "I should use my topical medication only when acne is present."
Answer: 3, 4, 5 Explanation: 1. Washing the face with an approved cleanser each day indicates appropriate understanding of prevention and treatment for acne. 2. Performing frequent hand hygiene and not touching the face indicates appropriate understanding of prevention and treatment for acne. 3. There is no evidence to suggest that greasy foods, such as pizza, cause acne. This statement indicates the need for further education. 4. Hair should be shampooed frequently, as the oil hair can cause acne. This statement indicates the need for further education. 5. Prescribed topical medication should be used daily and spread over the entire face. This statement indicates the need for further education. Page Ref: 1569
5) Which is the priority intervention when planning care for an infant who is diagnosed with eczema? 1. Applying antibiotics to lesions 2. Keeping the baby content 3. Maintaining adequate nutrition 4. Preventing infection of lesions
Answer: 4 Explanation: 1. Antibiotics are not routinely applied to the lesions, since the lesions are not related to infection. However, impaired skin barrier function and cutaneous immunity place the infant at greater risk for the development of skin infection. 2. Keeping the infant content is not as high a priority as is prevention of infection. An infant with eczema is at a greater risk for the development of skin infection. 3. Maintaining adequate nutrition is important, but it is not as high a priority. Due to impaired skin barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infection. 4. Nursing care should focus on preventing infection of lesions. Due to impaired skin barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infections by organisms. Page Ref: 1565
11) The toddler pulled a pot of boiling water off the stove and suffered partial- and full-thickness burns to the chest. The child is now in the recovery-management phase of burn treatment. Which common complication should the nurse assess this client for based on the current data? 1. Asphyxia 2. Metabolic acidosis 3. Shock 4. Wound infection
Answer: 4 Explanation: 1. Asphyxia is not a common complication during the recovery-management phase of burn treatment. Infection of the burned area is a frequent complication. 2. Metabolic acidosis is not common in the recovery-management phase of burn treatment. Infection of the burned area is a frequent complication. 3. Shock is not the most common complication during the recovery-management phase of burn treatment. Infection of the burned area is a frequent complication. 4. Infection of the burned area is a frequent complication in the recovery-management phase. A goal of burn-wound care is protection from infection. Page Ref: 1583
2) Which finding noted by the school nurse while conducting pediculosis capitis (head lice) checks would indicate the need for treatment? 1. White, flaky particles throughout the entire scalp region 2. Lesions on the scalp that extend to the hairline or neck 3. Maculopapular lesions behind the ears 4. Silver/white sacs attached to the hair shafts in the occipital area
Answer: 4 Explanation: 1. Lice and nits must be distinguished from dandruff, which appears as white, flaky particles. 2. Lesions might be present from itching, but the positive sign of head lice is evidence of nits. 3. Lesions might be present from itching, but the positive sign of head lice is evidence of nits. 4. Evidence of pediculosis capitis includes silver/white sacs (nits) that are attached to the hair shafts, frequently in the occiput area. Page Ref: 1572
23) Which interventions should the nurse include in the plan of care for a pediatric client who suffered a full-thickness burn injury to decrease the risk for infection? Select all that apply. 1. Using an age-appropriate assessment scale 2. Covering the affected skin as much as possible 3. Providing analgesics prior to wound care 4. Keeping the skin as clean and dry as possible 5. Clipping hair around the wound
Answer: 4, 5 Explanation: 1. Pain assessment with an age-appropriate scale is an appropriate intervention to address pain, not infection. 2. Covering the affected area to prevent temperature changes and air movement is an appropriate intervention to address pain, not infection. 3. Analgesics administration prior to wound care is an appropriate intervention to address pain, not infection. 4. Keeping the skin as clean and dry as possible is an appropriate intervention to decrease infection. 5. Clipping hair around the wound is an appropriate intervention to decrease infection. Page Ref: 1581-1582
