chapter 23 peds final

The school nurse has completed an educational program on first aid practices in the home. Which statement about burn care by a participant would indicate a need for further education? "I guess my mom was right; she always put ice on our burns when we were kids." "If my child has a superficial burn, I will run cool water over it." "Mild soap can be used to clean a superficial burn." "For a superficial burn, I can cover it with a clean nonadherent dressing."

"I guess my mom was right; she always put ice on our burns when we were kids." Explanation: Steps for providing burn care at home to a first-degree (superficial) burn include running cool water, not ice, over the burn and covering it with a nonadherent bandage after cleaning with a fragrance-free mild soap. Other care includes not applying butter, ointments or creams; and administering acetaminophen or ibuprofen for pain.

The nurse is caring for a child with burns in a pediatric hospital. What would be an appropriate nursing diagnosis for this client? Knowledge deficit related to daily care procedures in the acute care setting Risk for fluid volume overload related to thermal injuries Acute pain related to thermal injuries and procedures Risk for aspiration related to effects of medication

Acute pain related to thermal injuries and procedures Explanation: Management of acute pain is crucial for the burn client. Knowledge of the daily procedures at the acute care setting is not a priority for this child. Risk for aspiration would not be an appropriate nursing diagnosis.

The nurse is caring for a 9-year-old child with partial-thickness (second-degree) burns. The client rates the pain at an 8 on a 1 to 10 numerical pain scale. The nurse notes the client is sitting in the bed playing with toys and smiling. Which action will the nurse take? Administer pain medication as prescribed. Reassess the client's pain in 30 minutes. Ask the parents to rate the client's pain. Use another pain scale to measure the client's pain.

Administer pain medication as prescribed. Explanation: The nurse would administer the client pain medication as prescribed. Pain is how a client describes and rates it, regardless of outward appearances. The nurse should not allow the child to continue to feel pain while waiting an additional 30 minutes, asking the parents their opinion, or using a different pain scale.

A school-aged child is brought to the office of the camp nurse with a small, superficial burn (first-degree burn). Which action by the nurse would be most appropriate to take first? Apply a topical anesthetic ointment. Administer acetaminophen. Cover the area with a sterile bandage. Apply cold compresses to the area.

Apply cold compresses to the area. Explanation: Cool water is an excellent emergency treatment for burns involving small areas. The immediate application of cool compresses or cool water to burn areas appears to inhibit capillary permeability and thus suppress edema, blister formation, and tissue destruction.

The nurse is caring for a child with a second-degree (partial-thickness) burn. What assessment findings would the nurse expect to observe? Edema with wet blistering skin Reddened and leathery skin Edema with dry or waxy-looking skin Peeling skin with eschar

Edema with wet blistering skin Explanation: Partial-thickness or second-degree burns are very painful and edematous and have a wet appearance or the presence of blisters. Third-degree (full-thickness) burns appear red, edematous, leathery, dry, or waxy and may display red or charred skin (eschar).

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? Give the parent a hug. .Tell the parent to be thankful that the child is alive. Encourage the parent to talk more about feelings. Tell the parent he or she could not have prevented the fire

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.

The nurse is planning an educational program on burn prevention at home. Which information should be included? Select all that apply. Keep hot water heater temperature lower than 130°F (54.4°C). Keep pot handles turned in on a stove. Test bath water temperature before bathing children. If drinking hot beverages while holding children, keep them in an insulated cup with a lid. Teach children to "stop, drop and roll" if their clothes catch on fire.

Keep pot handles turned in on a stove. Test bath water temperature before bathing children. Teach children to "stop, drop and roll" if their clothes catch on fire. Explanation: Burn prevention techniques include keeping hot water heater temperature set at 120°F (48.9°C) or lower, not 130°F or lower. Do not drink hot beverages while holding children. Other techniques include keeping pots on the inside of the stove with the handles turned in, testing bath water before bathing a child, and teaching the child to 'stop, drop and roll' if their clothes catch on fire.

The nurse is caring for a child with suspected child abuse (child mistreatment)-induced burns. Which assessment findings would support this? a burn to the entire right hand up to 2 cm above wrist with consistent edges consistent history given by all caregivers splattered-looking, small burned areas to both legs 911 called immediately after the burn occurred

a burn to the entire right hand up to 2 cm above wrist with consistent edges Explanation: A stocking/glove pattern on the hands or feet (circumferential ring appearing around the extremity, resulting from a caregiver forcefully holding the child under extremely hot water) is one sign of child abuse (child mistreatment)-induced burns. Inconsistent history given by caregivers, delay in seeking treatment by caregivers, and a lack of splattering of water burns are all indicators of child abuse (child mistreatment)-induced burns.

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

full-thickness or third-degree Explanation: Full-thickness or third-degree burns may be very painful or numb or pain-free in some areas. They appear red, edematous, leathery, dry, or waxy and may display peeling or charred skin.

A child is hospitalized with burns over 25% of the body. The nurse is preparing to perform a dressing change. What aspect of changing the child's dressings is most important for the nurse to consider? pain management therapeutic communication activities for distraction infection prevention

infection prevention Explanation: Preventing infection is the most important aspect of burn wound care that the nurse should consider. Burn wound infections can quickly progress to life-threatening sepsis. Communicating therapeutically with the child, providing distraction activities, and pain management are important aspects to consider but preventing infection is most important.

An intensive care nurse has received the above hand-off report from the emergency department nurse. Thirty minutes later, the nurse assesses the child again. Which assessment finding should the nurse investigate further? (look at burns 1 image) blood pressure 100/56 mm Hg temperature 100.5°F (38.1°C) O2 saturation 96% (0.96) on 2L Pain level 8 out of 10

temperature 100.5°F (38.1°C) Explanation: The nurse should investigate the increased temperature, because it could be a sign of infection or a response to injury. The child's blood pressure and oxygen saturation has changed minimally. The pain level has decreased slightly and will need to be monitored. However, the temperature is increasing and should be investigated.

A child with a burn injury is scheduled for skin grafting. Which intervention would be most appropriate for the nurse to include in the child's plan of care? Provide around the clock pain medication. Administer analgesics when the child reports pain. Provide diversional activities for the client. Provide an egg crate mattress or gel mattress for the client to lie upon.

Provide around the clock pain medication. Explanation: When the child undergoes a procedure, such as skin grafting, that is known to produce prolonged pain, administer pain medication on a scheduled basis—rather than as needed—once pain is reported. Around the clock pain medication will serve to diminish peaks and valleys in pain relief. Diversional activities and an egg crate mattress are not effective treatments for severe pain.

The nurse is caring for a client with burns in a pediatric hospital. The child is scheduled to be discharged the following day and the nurse is going over discharge education with the parents. Which is the best intervention for the parents when removing an old dressing? Take your time and be thorough when changing the burn dressing. Remove the old dressing as quickly as possible. Soak the old dressing in cold normal saline before attempting to remove. Soak the old dressing in tepid water before attempting to remove.

Soak the old dressing in tepid water before attempting to remove. Explanation: Instruct the parents to soak the dressing in tepid water before removing it, to loosen the dressing and to decrease the child's discomfort. Removing the old dressing too quickly could cause stripping of new skin and tissue that is attached to the dressing. Dressing changes are done as quickly as possible once the old dressing has been removed since exposure to air and water causes pain.

A young child has just been admitted to the emergency department with a burn that encompasses the epidermis and the underlying dermis. From which type of burn does this child suffer? First-degree or superficial burn Second-degree or partial-thickness burn Third-degree or full-thickness burn Fourth-degree or fat-layer burn

Second-degree or partial-thickness burn Explanation: A burn that encompasses the epidermis and the underlying dermis is a second-degree burn. A first-degree burn would only involve the epidermis, and a third-degree burn would involve nerve endings as well as destruction of the epidermis and dermis. A fourth-degree burn would extend even deeper into the fat layer.

The nurse is developing the plan of care for a child who has suffered a major burn and has just been admitted to the acute care facility. Which nursing diagnosis would be most appropriate? Knowledge deficit related to daily care procedures in the acute care setting Risk for fluid volume overload related to thermal injuries Acute pain related to thermal injuries and procedures Risk for aspiration related to effects of medication

Acute pain related to thermal injuries and procedures Explanation: Management of acute pain is crucial for the client with a burn. Knowledge of the daily procedures at the acute care setting is not a priority for this client. A child with a burn would most likely experience fluid volume deficit due to the fluid loss associated with burns. Risk for aspiration would not be an appropriate nursing diagnosis.

A nurse is providing care to a 3-year-old child hospitalized with second-degree (partial-thickness) and deep partial-thickness burns to the dorsal portion of both legs. The nurse is preparing to change the child's dressings. Which action(s) should the nurse take to elicit the child's cooperation in the dressing change? Select all that apply. Have the parent instruct the child to cooperate with the nurse. Tell the child to watch television while the dressing is changed. Allow the child to decide which leg's dressing to change first. Permit the child to choose a method of distraction. Encourage the parent to hold the child's hand during the dressing change.

Allow the child to decide which leg's dressing to change first. Permit the child to choose a method of distraction. Encourage the parent to hold the child's hand during the dressing change. Explanation: The best actions for the nurse to take to elicit the child's cooperation are to allow the child to choose which leg to start with and to choose a method of distraction. Encouraging the parent to hold the child's hand during the dressing change is also helpful as a form of distraction. Having the parent instruct the child to cooperate or telling the child to watch television during the dressing change are not very helpful. These options are more authoritarian and do not include the child's preferences in his or her care.

Which intervention is the most beneficial for a burn client undergoing a skin graft? Provide around-the-clock pain medication as soon as pain is reported. Provide pain medication on a PRN schedule as soon as pain is reported. Provide diversional activities for the client. Provide an egg-crate mattress or gel mattress for the client to lie upon.

Provide around-the-clock pain medication as soon as pain is reported. Explanation: When the child undergoes a procedure, such as skin grafting, that is known to produce prolonged pain, administer pain medication on a scheduled basis, rather than as needed once pain is reported. Around-the-clock pain medication will serve to diminish peaks and valleys in pain relief. Diversional activities and an egg-crate mattress are not effective treatments for severe pain.

Which intervention is the most beneficial for a burn client undergoing a skin graft? Provide around-the-clock pain medication as soon as pain is reported. Provide pain medication on a PRN schedule as soon as pain is reported. Provide diversional activities for the client. Provide an egg-crate mattress or gel mattress for the client to lie upon.

Provide around-the-clock pain medication as soon as pain is reported. Explanation: When the child undergoes a procedure, such as skin grafting, that is known to produce prolonged pain, administer pain medication on a scheduled basis, rather than as needed once pain is reported. Around-the-clock pain medication will serve to diminish peaks and valleys in pain relief. Diversional activities and an egg-crate mattress are not effective treatments for severe pain.

A toddler pulled a cup of hot coffee off the table, causing first-degree (superficial) burns on the hands. The parent calls the clinic and asks what actions to take. How should the nurse respond? Select all that apply. Quickly run cool water over the toddler's hands. Apply ice to the burn to help with the pain. Apply burn cream to the hands after cleansing. Cover the burns with a clean nonadhesive bandage. Set up an appointment with the health care provider.

Quickly run cool water over the toddler's hands. Cover the burns with a clean nonadhesive bandage. Set up an appointment with the health care provider. Explanation: Suggested care for first-degree (superficial) burns includes running cool water over the burned area until the pain lessens; not applying ice, butter, ointment, or cream to the skin; covering the burn lightly with a clean, nonadhesive bandage; and administering acetaminophen or ibuprofen for pain. The nurse should suggest setting up an appointment within 24 hours.

The nurse is caring for a child on the burn unit weighing 100 lb (45.5 kg) who has second-degree (partial-thickness) burns over 30% of the body. During the beginning shift assessment, which assessment finding is of most concern to the nurse? Pain at a 7 on a 0 to 10 scale Urine output of 15 ml per hour over the last 4 hours Refused dinner due to nausea Weight gain of 0.9 kg over the last 2 days

Urine output of 15 ml per hour over the last 4 hours Explanation: Fluid and electrolyte imbalance is a primary concern when caring for the client with burns. The urine output should be a minimum of 1 ml/kg/hour. The client weighs 45.5 kg, so output should equal approximately 45 ml/hour. Pain is a major concern, but the higher priority at this time is the decreased output. Refusal of one meal is not a high priority. Weight gain of 0.9 kg over 2 days is not a concern at this time.

A child is hospitalized with burns over 25% of the body. The nurse is preparing to perform a dressing change. What aspect of changing the child's dressings is most important for the nurse to consider? therapeutic communication pain management infection prevention activities for distraction

infection prevention Explanation: Preventing infection is the most important aspect of burn wound care that the nurse should consider. Burn wound infections can quickly progress to life-threatening sepsis. Communicating therapeutically with the child, providing distraction activities, and pain management are important aspects to consider but preventing infection is most important.

The nurse is caring for a 7-year-old with burns. Which finding would be highly suggestive of a burn induced by child abuse (child maltreatment)? stocking-glove pattern on hands or feet splash patterns nonuniform pattern spattering pattern

stocking-glove pattern on hands or feet Explanation: A stocking-glove pattern on the hands or feet or a circumferential ring appearing around the extremity points to the caregiver forcefully holding the child under extremely hot water. A nonuniform pattern and splash or spattering patterns are not typical indicators of child abuse (child maltreatment).

A child enters the acute care setting following a burn injury. The nurse should check for which immunization booster? tetanus pertussis diphtheria meningitis

tetanus Explanation: For any burn, the nurse should check the child's tetanus immunization status on admission and ensure that tetanus toxoid is given if the child's immunizations are not up to date. Anaerobic and aerobic bacteria can grow at the interface between burned and healthy tissue, causing infection and possible sepsis. Pertussis, diphtheria, and meningitis are communicable diseases and, therefore, not related to burn injuries.

A nurse is caring for a child with second- and third-degree (partial- and full-thickness) burns over 15% of the body. The child reports severe itching in and around the burn sites. Which action would be most appropriate for the nurse to perform? Administer diphenhydramine. Turn the child every 2 hours. Soak the child in a colloidal bath. Provide diversional activities.

Administer diphenhydramine. Explanation: As nerve endings heal they cause intense itching that can be relieved with the use of medications (e.g., diphenhydramine hydrochloride, loratadine) and by applying soothing lotions such as Nivea or Eucerin. Turning the child every two hours will not relieve the itching. Soaking in a colloidal bath is contraindicated with burn clients. Although diversional activities can help somewhat, they will not relieve the child's itching.

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. Pain is at a tolerable level. Wounds remain infection-free. Fluid balance is maintained.

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

The nurse is completing the care plan for a pediatric client with deep partial-thickness or second-degree burns on the back and legs. Debridement of the burns is performed 2 to 3 times per week. What nursing diagnosis has the highest priority in regard to this treatment modality? Impaired skin integrity Pain Disturbed body image Risk for fluid volume deficit

Pain Explanation: Debridement involves the removal of loose skin and eschar (dead, charred skin). This procedure is usually performed with sterile scissors and a pair of forceps or with a gauze sponge. Debridement is a necessary, but often excruciatingly painful, procedure. Thus, pain management needs of the child are of utmost importance. All of the nursing diagnoses would be applicable to a burn client, but pain is the highest priority in regards to debridement.