Peds. Ch. 29 Integumentary

A school nurse has discovered that one of the children has acquired a case of head lice. The school principal asks the nurse to write a letter that will be sent to parents explaining about head lice and measures to prevent infestation. What information is important for the nurse to include in the letter? Select all that apply.

Children should avoid sharing personal items such as combs and hats. Parents should inspect their child's head for nits with a fine tooth comb. A second treatment one week after the first is recommended. Explanation: To prevent head lice infestation children should avoid sharing personal items such as barrettes, combs, and hats. Parents should also wash and dry clothes, bedding, and hats using high temperatures. Vacuuming soft surfaces that cannot be laundered (sofas and chairs) is also helpful. Parents should inspect their child's head daily with a fine tooth comb for nits (lice eggs) after treatment. A second treatment is often necessary 1 week to 10 days after the first. A head lice infestation can happen to any child and is not a reflection of poor hygiene or socioeconomic status. Shampoos with specific medications are necessary to treat head lice (permethrin).

The nurse is teaching the parents of a 5-year-old child diagnosed with head lice about using permethrin. The nurse determines that the teaching was successful based on which statement by the parents?

"We need to leave the medication on for about 10 minutes before rinsing it off." Explanation: Treatment of head lice begins with pediculicidal agents. Permethrin is the treatment of choice and is an over-the-counter drug. The parents should wash the child's hair before applying the medication, apply the medication to wet hair, leaving it on for 10 minutes before rinsing. One treatment is often not sufficient, and the treatment should be repeated in 7 days. Permethrin kills the live adult head lice but is not ovicidal, meaning that it does not kill the nits. Nits should be removed from wet hair with a specialized nit comb. Malathion is used for head lice infestations that do not respond to permethrin. This medication is applied to dry hair and scalp and left on overnight. Nit removal is still needed when this medication is used.

A nurse is providing care to an infant who is admitted with burns over the face, neck and chest. The nurse identifies which goal as priority for planning the infant's care?

Airway remains patent Explanation: The priority goal is maintain a patent airway especially because the burns affect the face and neck. Adequate output, maintaining pain at a tolerable level, and having the burns infection free are all appropriate goals for this infant, but maintaining a patent airway is the priority.

The rash in roseola is pruritic. Which measure would you teach the parent to provide comfort?

Apply cool compresses to the skin to stop local itching. Explanation: Rashes can be uncomfortable and irritating. Parents need to be educated on ways to relieve discomfort and to protect and maintain skin integrity. Cool compresses or cool baths will help to relieve the itching associated with the rash. Antipuretics may be necessary also to help with itching. To protect the skin the child should be instructed not to scratch the skin to alleviate itching. The child's fingernails should be kept short. Keeping the child dressed warmly will not bring out the rash any sooner. Being warm will, however, cause an increased temperature and intensify the itching. Aspirin should not be used in children as an antipyretic. There is an increased risk of developing Reye's syndrome.

What is a true statement regarding measles?

The incubation period is 10 to 12 days. Explanation: Measles is a highly contagious disease spread via droplets from the nasopharyngeal secretions.The typical incubation period is 10 to 12 days. Outbreaks peak in the winter and spring. It is communicable 1 to 2 days before the onset of symptoms. The initial symptoms are fever, cough, coryza and conjunctivitis. These symptoms are followed by Koplik spots seen in the mouth. A rash develops on the head and spreads downward and outward.

Which of the following is a true statement regarding measles?

The incubation period is 10 to 12 days. Explanation: The typical incubation period is 10 to 12 days. Outbreaks peak in the winter and spring. It is highly contagious and is transmitted by airborne suspended droplets.

The appearance of which hallmark clinical manifestation occurs in measles?

Koplik spots Explanation: The hallmark symptom of measles is the appearance of Koplik spots. These occur a few days before the outbreak of the rash. They are classic in appearance, described as a red ring around white dots. They occur on the buccal mucosa generally around the first and second molars. Measles has fever, conjunctivitis, and a cough as prodromal symptoms, but these are not definitive for measles as they can occur with many other illnesses.

A 30-month-old child has been discharged from the hospital after receiving treatment for partial-thickness burns over 6% of the body. One week later, the parent calls the nurse to say that the child has been drinking from a cup for one year, but is now constantly pulling at the mother's breast trying to nurse and refuses to drink from a cup. What is the best way for the nurse respond?

Explain that children who have had a serious injury sometimes exhibit regressive behavior Explanation: The best response is for the nurse to explain that children recovering from serious injuries such as burns will often regress in their behaviors. There is no indication for the parent to bring the child to the clinic for evaluation. It is inappropriate to tell the parent to allow the child to nurse as much as he or she wants. If the child has been weaned for one year, the mother likely has no breast milk. At 30 months, the child may not understand fully that he or she cannot nurse any longer. The parent can be supportive to the child, comforting the child with hugs and cuddling, and reinforcing the desired behavior.

A nurse is providing care to a child with partial and full thickness burns over 26% of the body. In monitoring the child's output the nurse expects an output of 1 to 2 mL/kg/hr. The nurse has emptied 46 mL from the foley catheter for the past hour. The child weighs 62 lb (28 kg). What action should the nurse take?

Document the output and continue to monitor Explanation: The nurse multiplies the client's weight in kilograms by the expected output. 28 kg × 1mL = 28 mL/hr The output of 28 mL/hr is within normal limits, so the nurse should document it and continue to monitor the output. There is no indication to notify the health care provider that the output is low. There is no indication to increase the IV fluid rate and doing so may not compensate for a low output. Maintaining proper fluid balance in a client with burns is a challenging and constantly changing process. There is no indication to check the catheter for kinks because the output is within normal limits.

A 5-year-old child is brought to the pediatric health clinic for evaluation. The nurse completes the assessment and documents the findings. Based on the assessment findings above, which condition would the nurse suspect?

Measles Explanation: The assessment findings suggest measles (rubeola). Children initially present in the prodromal, or early symptom, phase. During this phase, children experience mild fever, conjunctivitis, coryza, and cough. Conjunctival drainage is nonpurulent. Koplik spots, which are clustered white lesions, may or may not be apparent on the oral mucosa at the time of presentation. However, Koplik spots appear within 4 days of the rash onset. Fever is highest 1 to 2 days before the appearance of the rash. The rash is maculopapular, beginning at the head and progressing down the trunk and upper extremities. Rubella is characterized by a prodromal period consisting of fever, malaise, headache, sore throat, and red eyes. The rash begins on the face and neck as irregular macules. The rash on the face disappears as it spreads to the trunk and lasts no longer than 3 days.Varicella is characterized by prodromal symptoms including fever, malaise, and headache for 24 to 48 hours before the eruption of lesions. Skin lesions appear in various stages. New lesions appear as old ones scab over. The lesion begins as an erythematous macule and progresses to a pustule and finally a clear fluid-filled vesicle. The rash is severely pruritic. Children with cellulitis often have fever, chills, and lymphadenopathy. Infected areas are erythematous and warm to thetouch and may be edematous and painful. There is no rash with cellulitis.

An infant is seen in the emergency department with several raised red welts over the abdomen and lower extremities. The parent states that the symptoms developed suddenly over the past few hours. The infant is fussy and has a low grade temperature. What assessment is most important for the nurse to perform?

Observe the infant's respiratory effort Explanation: The raised red welts are likely urticaria or hives, an allergic response to a substance (food, drugs, plants, etc.). As such, it is most important to observe the infant's respiratory effort since that reaction can involve the lips, tongue and airway. Cyanosis would not be visible unless the airway was blocked and then it would be central cyanosis, not just circumoral. Questioning the parent about methods of punishment is unnecessary as the welts are not a sign of trauma. It is appropriate to determine if the infant is breastfed or formula fed because it might be related to the hives the especially if the infant was switched from breast milk to formula, but it is not the most important assessment.

A nurse completes an assessment on an 8-month-old infant seen in the pediatrician's office for a well-child visit. The nurse notes that the infant's buttocks, perineum and inner thighs are covered in a thick coating of white ointment. When questioned, the parent says the infant has a diaper rash and the ointment is to protect the infant's skin. What is the best action for the nurse to take?

Provide instruction on how to care for a diaper rash. Explanation: The best action for the nurse to take is to provide instruction on how to care for a diaper rash. This would include changing diapers frequently to prevent a rash, how to apply rash ointment, and how using too much ointment can cause the infant's skin to absorb the ointment. It is important to praise parents on taking good care of their child, but the best action is to provide instruction on the correct way to do so.

The nurse is providing care to a 5-year-old child brought to the emergency department with a cat bite wound on the arm. While teaching the parents how to care for the wound, the child's mother asks the nurse, "Why isn't the bite being stitched closed?" Which response by the nurse would be appropriate?

"Bites from cats are likely to become infected, so it is better to leave the wound open and heal from the inside out." Explanation: Cat bite wounds are more likely to become infected because of the nature of the puncture wound. Cat bite wounds are left open to heal by secondary intention because of the high rate of infections associated with these types of bites. Saying that it is too early to close the wound or that the child needs to be seen by a plastic surgeon or have a tetanus vaccine is inappropriate.

When providing care for a child with herpes zoster (shingles), the parents ask the nurse how the child contracted this infectious disorder. Which response by the nurse is most appropriate?

"Herpes zoster is a reactivation of a previous varicella zoster infection." Explanation: Herpes zoster (shingles) is reactivation of the latent varicella zoster (chicken pox) infection that occurs during times of immunosuppression and aging. Although it is possible to contract the varicella zoster virus from a person with herpes zoster or varicella zoster, a child diagnosed with herpes zoster has already been exposed to varicella zoster. Handwashing will not directly prevent herpes zoster.

A nurse is teaching a group of parents about burn safety. Which statement made by a parent requires intervention by the nurse?

"I had our plumber lower our water heater temperature to 130°F (53°C). Explanation: Water heater temperature should be 120°F (49°C) or lower to prevent significant burns. Installing smoke detectors on every floor of a home is recommended. Keeping young children out of the kitchen during food preparation is important. Teaching children to stop, drop, and roll is important for fire safety.

The nurse is assessing the skin of a 6-year-old child with urticaria. When interviewing the child and parents, which question would be most important for the nurse to ask?

"Is the child having any trouble breathing?" Explanation: Although all the questions are important to obtain information about the urticaria, asking about any difficulty breathing is the priority question. Urticaria is caused by an allergic trigger and anaphylaxis is always a concern. If the child experiencing breathing difficulties, the nurse would need to intervene immediately to ensure airway and breathing. Once airway and breathing are ensured, the nurse can gather additional information.

The parent of a child diagnosed with nonbullous impetigo brings the child back to the clinic. The parent states, "I am doing what I am supposed to for my child, but the lesions have not gone away yet." The child began treatment with a topical antibiotic ointment 7 days ago. Which response by the nurse is most appropriate?

"It takes 10 to 14 days for the lesions to decrease." Explanation: Typically, treatment for nonbullous impetigo with a topical antibiotic ointment lasts for 10 to 14 days with the expected outcome that the presence of the lesions will decrease over this time. Since it is only been 7 days since treatment started, the lesions would not be expected to be gone in this period of time. There is no evidence to support a secondary infection or another type of skin infection. The medicine is given for 10 to 14 days, so it would be inappropriate to tell the parent that the medication is taking longer to treat the infection.

A new parent brings the 3-month-old infant to the clinic for a well-baby check up. During the visit, the parent asks the nurse, "I know the rays from the sun can be harmful, so what should I do to protect my infant?" Which suggestion by the nurse would be most appropriate?

"The best thing to do is keep any infant under the age of 6 months out of the sun." Explanation: For infants under the age of 6 months, it is best to keep them out of the sun to reduce their risk of exposure to the sun's damaging rays. Sunscreen should be applied sparingly in infants younger than 6 months. As the infant gets older, he or she should have sunscreen of at least 15 SPF applied to all exposed areas and have it reapplied every 2 hours or after swimming or sweating. Clothing with SPF built in, a wide-brimmed hat, and umbrellas for shade are appropriate once the infant is over the age of 6 months.

A 6-year-old child is brought to the clinic for evaluation of a rash. The nurse completes an assessment of the child's skin and documents the findings above. Based on the findings, which information would the nurse include in the teaching plan for the child's parents?

"Use a patting motion, not a rubbing motion, to dry the child's skin." Explanation: For skin disorders that cause itching, the nurse would instruct the parents to pat the skin dry and not to rub it. The nurse would also teach the parents to place the child in a lukewarm bath, using a commercial oatmeal bath product, if desired, and to apply antibiotic ointment, hydrocortisone cream, or moisturizers while the skin is still damp. The child should wear loose clothing to promote air circulation and avoid sweating, which could exacerbate pain and itching.

A nurse is providing care for a child who requires intravenous fluid replacement. The child has burns over 32% of the body and weighs 40 lb (18.1 kg). Using the above formula, how much fluid should the nurse administer over the first 8 hours? Record your answer using one decimal place.

1158.4 Explanation: 4 mL × 32% × 18.1 kg = 2316.8 mL 2316.8 mL × 1/2 = 1158.4 mL over 8 hours

A child weighing 66 lb (30 kg) with deep partial thickness burns is receiving fluid resuscitation. The nurse is monitoring the child's urine output via Foley catheter every hour and documenting the findings on the flowsheet above. The nurse would notify the health care provider about which urine output?

56 mL Explanation: It is important to maintain adequate fluid volume in a child with burns. The nurse would monitor urine output via a Foley catheter, and notify the health care provider if output is less than 2 mL/kg/h. The child weighs 66 lb (30 kg). So an adequate hourly urine output for this child would be 60 mL/hr. Therefore the nurse would notify the health care provider for a urine output of 56 mL.

After teaching the parents of a child with varicella zoster, the nurse determines that the parents have understood the teaching when they state that their child can return to school at which time?

After the lesions have crusted Explanation: Children with chickenpox (varicella zoster) can return to school once the lesions have crusted.

A parent is observing a nurse provide care for the parent's 2-year-old toddler who was burned in a house fire. When the nurse is finished, the parent tells the nurse "I cannot believe this has happened. I should have been able to prevent this from happening." What is the best action for the nurse to take?

Encourage the parent to talk more about feelings Explanation: The best action for the nurse to take is to encourage the parent to talk about his or her feelings. This gives the parent the opportunity to share feelings and concerns. Giving the parent a spontaneous hug may not be welcomed. Telling the parent he or she could not have prevented the fire or to be thankful that the child is alive is not therapeutic and negates the parent's feelings.

A parent brings an infant to the clinic for a well child visit. During the assessment, the parent asks the nurse why the infant never seems to sweat. What action should the nurse take?

Explain that this normal mechanism keeps the infant from losing too much water through the skin. Explanation: The sweat glands of an infant are immature and this normal mechanism keeps the infant from losing too much insensible water. Because this is a normal occurrence, there is no reason to make a note to inform the health care provider or to refer the infant to a specialist. An infant's temperature does not run lower than an adult's temperature.

A nursing student learning about childhood infectious diseases correctly identifies which of the following as the disease related to chickenpox, which tends to occur in older children or young adults?

Herpes zoster Explanation: Herpes zoster is caused by varicella-zoster virus, the same virus that causes chickenpox.

A child is seen in the clinic because of a rash over the face and trunk area for the past 4 days. The nurse completes an assessment and suspects the child has rubeola. Which assessment finding best supports the nurse's suspicion?

Koplik spot Explanation: Koplik spots (bright red spots with white centers on the buccal mucosa) are specific to rubeola. Fever, pruritus, and malaise are common findings to both rubeola and rubella.

When describing measles to a local parent group, the nurse explains that which of the following is the hallmark clinical manifestation?

Koplik spots Explanation: The hallmark of measles is the appearance of Koplik spots. Other typical symptoms include fever, conjunctivitis, and a cough.

The nurse is obtaining a health history and assessment for a child being admitted who is suspected of having measles. What signs and symptoms does the nurse expect to find during the assessment? Select all that apply.

Maculopapular rash that began on the face and has spread to the rest of the body Fever Upper respiratory infection symptom Explanation: Maculopapular rash that began on the face and has spread to the rest of the body, fever, and upper respiratory infection symptoms are characteristic of both rubella (German measles) and rubeola (measles). Clear, fluid-filled vesicles are characteristic of chicken pox (varicella zoster. Erythematous flushing is common with erythema infectiosum (fifth disease).

A child is brought to the emergency department by his parents. The parents report that he stepped on a rusty nail about a week and a half ago. The child is complaining of cramping in his jaw and some difficulty swallowing. The nurse suspects tetanus. When assessing the child, the nurse would be alert to which muscle groups being affected next?

Neck Explanation: Tetanus progresses in a descending fashion to other muscle groups, causing spasms of the neck, arms, legs, and stomach.

When the health care provider looks in a child's mouth during a sick-visit examinaiton, the parent exclaims: "The tongue is bright red! It was not like that yesterday." The health care provider would most likely prescribe which medication based on the probable diagnosis?

Penicillin to prevent acute glomerulonephritis Explanation: A "strawberry tongue" is a classic sign of scarlet fever. Penicillin is prescribed to treat the beta-hemolytic group A strococcal infection and to prevent the complication of developing acute glomerulonephritis and rheumatic fever. Erythromycin can be used to treat the disease if the child is allergic to penicillin. Antibiotics are not give prophylactally to siblings. The disease is spread via droplets, so keeping the siblings away from the infected child and handwashing are the best preventative measures. Acetaminophen can be administered for fever control. It works systemically and has very little, if any, affect locally. Antibiotics are the mainstay of treatment. Steroids are used infrequently.

A mother brings her 8-year-old son for evaluation because of a rash on his lower leg. Which finding would support the suspicion that the child has Lyme disease?

Playing in the woods about a week ago Explanation: Lyme disease is caused by the bite of an infected tick, with a rash appearing 7 to 14 days after the tick bite. Ticks are commonly found in wooded areas. Therefore, reports of the child playing in the woods about 7 days ago would support the diagnosis of Lyme disease. A papular and vesicular rash is commonly associated with varicella (chickenpox). A high fever for 3 to 5 days before a rash suggests roseola. Extreme pruritus with visible nits would suggest pediculosis.

The nurse is caring for a 10-year-old child with a skin rash. The nurse should include which intervention to manage the associated pruritis?

Press the pruritic area Explanation: Pruritis may be managed by pressing on the area instead of scratching. Increases in temperature will result in vasodilation and increase the pruritis. Warm baths and hot compresses should be avoided. Rubbing may result in increased itching.

What information should be included in the teaching plan for a child with varicella?

Remind the child not to scratch the lesions. Explanation: Varicella lesions appear first on the scalp. They spread to the face, the trunk, and to the extremities. There may be various stages of the lesions present at any one time. The lesions are intensely pruritic. The teaching plan for varicella should include that the child not scratch the lesions. Opening the lesions gives access for secondary infection to occur and causes scarring. Acetaminophen, not aspirin, should be administered for fever due to the link with Reye syndrome. The best treatment for skin discomfort is a cool bath with soothing colloidal oatmeal every 3 to 4 hours for the first few days. Warm baths cause more itching and dry the skin.

A nurse is preparing a presentation for a group of parents of toddlers at the local community center. The topic of the presentation is burn prevention. When describing burns in toddlers, which situation would the nurse likely identify as the most common cause of thermal burns?

Scalding from pulling a hot pan off the stove Explanation: The most common type of thermal burns during the toddler years is scalding burns, which typically result from a child pulling a hot pan off of a stove or being immersed in bathwater that is too hot. Although less common, hot objects, such as irons, flat irons, curling irons, stoves, and ovens can also cause burns. During the school-age years, thermal burns are often caused by playing with matches, fireworks, or gasoline. Ingesting a household cleaning agent would lead to a chemical burn.

The nurse is doing an in-service training on clinical manifestations seen in communicable diseases. Which skin condition best describes pustule?

Small elevation of epidermis filled with a viscous fluid Explanation: A pustule is a small elevation of epidermis filled with pus.

The mother of a 4-year-old boy has contacted the physician's office. She reports her son was exposed to someone with chickenpox. She has inquired about when her son may show if he has gotten the disease. What information should be provided?

The incubation period for the disease is between 10 and 21 days. Explanation: Chickenpox is the common name for varicella. This condition has an incubation period of 10 to 21 days.

The nurse is administering a chicken pox vaccination to a 12-month-old girl. Which concern is unique to varicella?

This disease can reactivate years later and cause shingles. Explanation: Varicella zoster results in a lifelong latent infection. It can reactivate later in life resulting in shingles. The American Academy of Pediatrics recommends consideration of Vitamin A supplementation in children 6 months to 2 years hospitalized for measles. Dehydration caused by mouth lesions is a concern with foot and mouth disease. Avoiding exposure to pregnant women is a concern with rubella, rubeola, and erythema infectiosum.

The parents of a child diagnosed with varicella are concerned about their other children getting it. The nurse instructs the parents that their child is contagious for how much longer now that the rash has appeared?

Until there are no more new lesions and lesions have crusted over Explanation: With varicella, children are contagious 1 to 2 days before the rash appears and continue to be contagious until there are no more new lesions and all lesions are crusted over. Children with mumps are infectious for 7 days before parotid swelling and up to 8 days after the onset of swelling. A child with rubeola is contagious for 4 days vefore and 4 days after the appearance of the rash. The rash of rubella typically lasts no longer than 3 days.

The nurse is caring for multiple clients on the pediatric unit. Which child will the nurse see first?

a child with erythema infectiosum experiencing fatigue and confusion Explanation: A child with erythema infectiosum experiencing fatigue and confusion is showing signs of decreased oxygenation, possibly related to aplasia of erythrocytes caused by the virus. A child with signs and symptoms of decreased oxygenation should be seen first. Nausea and malaise are symptoms of chicken pox. A child with herpes simplex will most likely report pain an pruritis. Signs and symptoms of measles include photophobia and coryza.

A parent calls the nurse to discuss a rash. The nurse suspects that the rash possibly could be varicella when the parent describes rash characteristics as:

various stages of lesions present at the same time. Explanation: Chickenpox lesions may appear first on the face, scalp or trunk before spreading to the extremities. The rash starts as vesicles. The vesicles then erupt and form lesions. These lesions then scab over. During the course of the disease a variety of lesions may be present at any time. Maculopapular rashes are seen in rubella and rubeola and are dark red. The maculapular rash seen in erythema infectiosum is very puritic.

The nurse is inspecting the skin of a child with a rash on the lower legs and documents the above findings. Based on the findings, which question would the nurse most likely ask next?

"Was your child outside near some plants that could be poison ivy?" Explanation: The rash described in the documentation (linear patter with pustules and erythema) suggest allergic dermatitis associated with exposure to plants such as poison ivy. Therefore, the next question should focus on possible exposure to the plant oils. The questions about detergent or soaps would be appropriate if the rash suggested irritant dermatitis as demonstrated by a more diffuse pattern. Asking about metal in the child's clothing would be appropriate if the rash suggested nickel dermatitis, which would be typically found at the navel, belt line, or earlobes.

The nurse is discussing fever with the parents of a child who is in the emergency department with a temperature of 101 degrees Fahrenheit. Which statement by a parent indicates an understanding about fevers and their management in the ill child?

Fevers can be beneficial because they can slow down the growth of the bacteria or virus that may be causing the infection." Explanation: Fevers can be protective and can help the body fight the infection. Fevers slow down bacterial or viral growth. Mismanaging fevers include inappropriate dosing of antipyretics, awakening a child at night to administer antipyretics, and using cold water or sponging the child with alcohol to reduce the temperature.

The nurse is preparing a presentation at a local college about the signs and symptoms of mumps because several colleges in the area have had recent outbreaks. Which information would the nurse most likely include? Select all that apply.

Swelling just below and in front of the ear Fever Runny nose Explanation: Parotid gland swelling (just below and in front of the ear) is the hallmark presentation of mumps. A prodromal period of 1 to 2 days consists of fever, aches, and rhinitis. Once parotitis begins, the area is tender, often with ipsilateral ear pain. White lesions in the mouth and a rash on the trunk is associated with measles.

An adolescent is brought to the urgent care clinic for evaluation of the hands. The adolescent had been out snowboarding for the past several hours in 20oF (-6.7oC) temperatures. The adolescent was wearing gloves but took them off because they were wet and causing problems with holding onto the snowboard. The nurse completes an assessment and documents the findings. Based on the assessment findings above, which action would be appropriate as part of the plan of care?

Placing the hands in warm water for 30 minutes Explanation: The key to treating second-degree frostbite is to rewarm the affected area. Rewarming is accomplished by placing the affected areas in warm water at a temperature of 98.6°F (37°C) to 102.2°F (39°C) for at least 30 minutes. Wound care specialists and plastic surgeons would be involved with more severe (third-degree) frostbite. Massaging should be avoided because it can cause tissue damage. As the area is rewarmed, the color of the skin typically appears red to purple.