Wongs Ch 32: The Child with Integumentary Dysfunction

3. Which should the nurse include when teaching parents about preventing childhood burn injuries? (Select all that apply.) a. Keep hot liquids out of reach. b. Baby-proof electrical outlets. c. Turn water heater thermostats to a maximum of 150° F. d. Heat infant formula in the microwave. e. Test water temperature before placing your child in the tub bath.

, ANS: A, B, E To prevent burns hot liquids should be kept out of reach; tablecloths and dangling appliance cords are often pulled by toddlers, who spill hot grease and liquids on themselves. Electrical cords and outlets represent a potential risk to small children, who may chew on accessible cords and insert objects into outlets. The Consumer Product Safety Commission recommends a reduction of water heater thermostats to a maximum of 48.9° C (120° F). The increased use of microwave ovens has resulted in burn injuries from the extremely hot internal temperatures generated in heated items. Baby formula, jelly-filled pastries, and hot liquids and dishes may result in cutaneous scalds or the ingestion of overheated liquids. Water should always be tested before a child is placed in the tub or shower. PTS: 1 DIF: Cognitive Level: Apply REF: 1033 | 1047 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

1. A nurse is caring for a 5-year-old child with a major burn. The health care provider has written a prescription to notify the health care provider if urine output falls to or below 2 ml/kg/hr. The child weighs 55 lb. The nurse should notify the health care provider if the milliliters of urine output is at or below _____ for an hour. (Record your answer in a whole number.)

ANS: 50 The primary emphasis during the emergent phase is the treatment of burn shock and the management of pulmonary status. Monitoring vital signs, output, fluid infusion, and respiratory parameters are ongoing activities in the hours immediately after injury. IV infusion is begun immediately and is regulated to maintain a urinary output of at least 1 to 2 ml/kg in children weighing less than 30 kg (66 pounds). To calculate the child's weight in kilograms, the weight in pounds is divided by 2.2. That number is then multiplied by 2 to get the amount expected for a 1-hour period. 55/2.2 = 25 kg. 25 kg × 2 ml = 50 ml per hour. PTS: 1 DIF: Cognitive Level: Analyze REF: 1044 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

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

ANS: A Children who understand the procedure and have some perceived control demonstrate less maladaptive behavior. They respond well to participating in decisions and should be given as many choices as possible. The dressing change procedure is painful and stressful. Misinformation should not be given to the child. Analgesia and sedation can and should be used. Encouraging the child to master stress with controlled passivity is not a positive coping strategy. PTS: 1 DIF: Cognitive Level: Apply REF: 1046-1047 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Psychosocial Integrity: Coping and Adaptation

45. A child with extensive burns requires débridement. The nurse should anticipate which priority goal related to this procedure? a. Reduce pain. b. Prevent bleeding. c. Maintain airway. d. Restore fluid balance.

ANS: A Partial-thickness burns require débridement of devitalized tissue to promote healing. The procedure is painful and requires analgesia and sedation before the procedure. Preventing bleeding, maintaining the airway, and restoring fluid balance are not goals associated with débridement. PTS: 1 DIF: Cognitive Level: Apply REF: 1043 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

36. The most immediate threat to life in children with thermal injuries is: a. shock. b. anemia. c. local infection. d. systemic sepsis.

ANS: A The immediate threat to life in children with thermal injuries is airway compromise and profound shock. Anemia is not of immediate concern. During the healing phase, local infection or sepsis are the primary complications. Respiratory problems, primarily airway compromise, are the primary complications during the acute stage of burn injury. PTS: 1 DIF: Cognitive Level: Apply REF: 1040 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

44. Hydrotherapy is required to treat a child with extensive partial-thickness burn wounds. Which is the primary purpose of hydrotherapy? a. Débride the wounds. b. Increase peripheral blood flow. c. Provide pain relief. d. Destroy bacteria on the skin.

ANS: A The water acts to loosen and remove sloughing tissue, exudate, and topical medications. Increasing peripheral blood flow, providing pain relief, and destroying bacteria on the skin may be secondary benefits to hydrotherapy, but the primary purpose is for débridement. PTS: 1 DIF: Cognitive Level: Apply REF: 1043 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

, 4. The community health nurse is teaching parents about prevention of the spread and reoccurrence of pediculosis (head lice). Which should the nurse include in the teaching session? (Select all that apply.) a. Dryclean nonwashable items. b. Spray the environment with an insecticide. c. Seal nonwashable items in a plastic bag for 5 days. d. Boil combs and brushes for 10 minutes. e. Discourage sharing of personal items.

ANS: A, D, E To prevent the spread and reoccurrence of pediculosis the nurse should teach the parents to: dryclean nonwashable items, boil combs and brushes for 10 minutes or soak for 1 hour in a pediculicide, and discourage the sharing of personal items, such as combs, hats, scarves and other headgear. Spraying with insecticide is not recommended because of the danger to children and animals. Nonwashable items should be sealed for 14 days in a plastic bag. PTS: 1 DIF: Cognitive Level: Apply REF: 1028 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

34. A child is admitted with extensive burns. The nurse notes that there are burns on the child's lips and singed nasal hairs. The nurse should suspect that the child has a(n): a. chemical burn. b. inhalation injury. c. electrical burn. d. hot-water scald.

ANS: B Evidence of an inhalation injury is burns of the face and lips, singed nasal hairs, and laryngeal edema. Clinical manifestation may be delayed for up to 24 hours. Chemical burns, electrical burns, and those associated with hot-water scalds would not cause singed nasal hair. PTS: 1 DIF: Cognitive Level: Understand REF: 1040 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

49. Which is an important consideration for the nurse when changing dressings and applying topical medication to a child's abdomen and leg burns? a. Apply topical medication with clean hands. b. Wash hands and forearms before and after dressing change. c. If dressings adhere to the wound, soak in hot water before removal. d. Apply dressing so that movement is limited during the healing process.

ANS: B Frequent hand and forearm washing is the single most important element of the infection-control program. Topical medications should be applied with a tongue blade or gloved hand. Dressings that have adhered to the wound can be removed with tepid water or normal saline. Dressings are applied with sufficient tension to remain in place but not so tightly as to impair circulation or limit motion. PTS: 1 DIF: Cognitive Level: Apply REF: 1045 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

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

ANS: B In minor burns, the best method to stop the burning process is to hold the burned area under cool running water. Ice is not recommended. Removal of blisters is not generally accepted therapy unless the injury is from a chemical substance. Cooling is necessary to stop the burning process. PTS: 1 DIF: Cognitive Level: Apply REF: 1041 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

46. Biologic dressings are applied to a child with partial-thickness burns of both legs. Which nursing intervention should be implemented? a. Observing wounds for bleeding b. Observing wounds for signs of infection c. Monitoring closely for signs of shock d. Splinting legs to prevent movement

ANS: B When applied early to a superficial partial-thickness injury, biologic dressings stimulate epithelial growth and hasten wound healing. If the dressing covers areas of heavy microbial contamination, infection occurs beneath the dressing. In the case of partial-thickness burns, such infection may convert the wound to a full-thickness injury. Infection is the primary concern when biologic dressings are used. PTS: 1 DIF: Cognitive Level: Apply REF: 1043 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

33. Which best describes a full-thickness (third-degree) burn? a. Erythema and pain b. Skin showing erythema followed by blister formation c. Destruction of all layers of skin evident with extension into subcutaneous tissue d. Destruction injury involving underlying structures such as muscle, fascia, and bone

ANS: C A third-degree, or full-thickness, burn is a serious injury that involves the entire epidermis and dermis and extends into the subcutaneous tissues. Erythema and pain are characteristic of a first-degree, or superficial, burn. Erythema with blister formation is characteristic of a second-degree, or partial-thickness, burn. A fourth-degree burn is a full-thickness burn that also involves underlying structures such as muscle, fascia, and bone. PTS: 1 DIF: Cognitive Level: Understand REF: 1039 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

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

ANS: C Disorientation in the burn patient is one of the first signs of overwhelming sepsis and may indicate inadequate hydration. Seizures, bradycardia, and decreased blood pressure are not initial manifestations of overwhelming sepsis. PTS: 1 DIF: Cognitive Level: Understand REF: 1046 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

42. Fentanyl and midazolam (Versed) are given before débridement of a child's burn wounds. Which is the rationale for administration of these medications? a. Promote healing. b. Prevent infection. c. Provide pain relief. d. Limit amount of débridement that will be necessary.

ANS: C Fentanyl and midazolam provide excellent intravenous sedation and analgesia to control procedural pain in children with burns. These drugs are for sedation and pain control, not healing, preventing infection, or limiting the amount of débridement. PTS: 1 DIF: Cognitive Level: Understand REF: 1042 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

43. Nitrous oxide is being administered to a child with extensive burn injuries. Which is the purpose of this medication? a. Promote healing. b. Prevent infection. c. Provide anesthesia. d. Improve urinary output.

ANS: C The use of short-acting anesthetic agents, such as propofol and nitrous oxide, has proven beneficial in eliminating procedural pain. Nitrous oxide is an anesthetic agent. PTS: 1 DIF: Cognitive Level: Understand REF: 1042 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

35. Which explains physiologically the edema formation that occurs with burns? a. Vasoconstriction b. Decreased capillary permeability c. Increased capillary permeability d. Decreased hydrostatic pressure within capillaries

ANS: C With a major burn, an increase in capillary permeability occurs, allowing plasma proteins, fluids, and electrolytes to be lost. Maximal edema in a small wound occurs about 8 to 12 hours after injury. In larger injuries, the maximal edema may not occur until 18 to 24 hours. Vasoconstriction, decreased capillary permeability, and decreased hydrostatic pressure within capillaries are not physiologic mechanisms for edema formation in burn patients. PTS: 1 DIF: Cognitive Level: Analyze REF: 1040 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

37. After the acute stage and during the healing process, the primary complication from burn injury is: a. asphyxia. b. shock. c. renal shutdown. d. infection.

ANS: D During the healing phase, local infection and sepsis are the primary complications. Renal shutdown is not a complication of the burn injury, but may be a result of the profound shock. PTS: 1 DIF: Cognitive Level: Apply REF: 1040 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

38. An adolescent girl is cooking on a gas stove when her bathrobe catches fire. Her father smothers the flames with a rug and calls an ambulance. She has sustained major burns over much of her body. Which is important in her immediate care? a. Wrap her in a blanket until help arrives. b. Encourage her to drink clear liquids. c. Place her in a tub of cool water. d. Remove her burned clothing and jewelry.

ANS: D In major burns, burned clothing should be removed to avoid further damage from smoldering fabric and hot beads of melted synthetic materials. Jewelry is also removed to eliminate the transfer of heat from the metal and constriction resulting from edema formation. The burns should be covered, not wrapped with a clean cloth. A blanket can be used initially to stop the burning process. Fluids should not be given by mouth to avoid aspiration and water intoxication. The child should be kept warm. Placing her in a tub of cool water will exacerbate heat loss. PTS: 1 DIF: Cognitive Level: Apply REF: 1041 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

39. A young child has sustained a minor burn to the foot. Which is recommended for treatment of a minor burn? a. Apply ice to foot. b. Apply cortisone ointment. c. Apply an occlusive dressing. d. Cleanse the wound with a mild soap and tepid water.

ANS: D In minor burns, the best method of treatment is to cleanse the wound with a mild soap and tepid water. Ice is not recommended. Most practitioners favor covering the wound with an antimicrobial ointment (not cortisone) to reduce the risk of infection and to provide some form of pain relief. The dressing is not occlusive but consists of nonadherent fine-mesh gauze placed over the ointment and a light wrap of gauze dressing that avoids interference with movement. This helps keep the wound clean and protects it from trauma. PTS: 1 DIF: Cognitive Level: Apply REF: 1041 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

41. A parent of a child with major burns asks the nurse why a high-calorie and high-protein diet is prescribed. Which response should the nurse make? a. The diet promotes growth. b. The diet will improve appetite. c. The diet will diminish risks of stress-induced hyperglycemia. d. The diet will avoid protein breakdown.

ANS: D The diet must provide sufficient calories to meet the increased metabolic needs and enough protein to avoid protein breakdown. Healing, not growth is the primary consideration. Many children have poor appetites, and supplementation will be necessary. Hypoglycemia, not hyperglycemia, can occur from the stress of burn injury because the liver glycogen stores are rapidly depleted. PTS: 1 DIF: Cognitive Level: Apply REF: 1042 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort

50. The family of a 4-month-old infant will be vacationing at the beach. Which should the nurse teach the family about exposure of the infant to the sun? a. Use sun block on the infant's nose and ear tips. b. Use topical sunscreen product with a sun protective factor of 15. c. The infant can be exposed to the sun for 15-minute increments. d. Keep the infant in total shade at all times.

ANS: D The infant should be kept out of the sun or be physically shaded from it. Fabric with a tight weave, such as cotton, offers good protection. Infants should be covered with clothing or in the shade to prevent sun damage on the delicate skin at all times. The blocker can protect the nose and ear tips, but none of the infant's skin should be exposed. Sunscreens should not be used extensively on infants younger than 6 months. PTS: 1 DIF: Cognitive Level: Apply REF: 1048 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential