Chapter 23 : Skin disorders
A nurse is assessing a 6-month-old girl with an integumentary disorder. The nurse notes three virtually identically sized, round red circles with scaling that are symmetrically spaced on both of the girl's inner thighs. What should the nurse ask the mother?
"Does she wear sleepers with metal snaps?" Explanation: Small round red circles with scaling, symmetrically located on the girl's inner thighs, point to nickel dermatitis that may occur from contact with jewelry, eyeglasses, belts, or clothing snaps. The nurse should inquire about any sleepers or clothing with metal snaps. The girl does not have a rash in her diaper area. It is unlikely that an infant this age would have her inner thighs exposed to a highly allergenic plant. Discussing family allergy history is important, but the nurse should first inquire about any clothing with metal that could have come into contact with the girl's skin when she displays a symmetrical rash.
The parent of a 4-year-old child with atopic dermatitis reports having difficulty keeping the child from scratching. What information can be provided by the nurse? Select all that apply.
"Keep your child's finger nails trimmed and filed." "Distract your child with activities when you notice scratching." "Give your child a small stuffed animal or ball to squeeze when the child itches instead of scratching." "Keep a diary of triggers for a week to see what patterns your child has related to this problem." Explanation: Itching is a chief concern with atopic dermatitis. Strategies should be employed to reduce scratching. Keeping the fingernails trimmed is helpful in preventing cuts to the skin and introducing bacteria to open wounds. Distracting the child with activities is helpful when the child is experiencing sensations of itching. A small ball or stuffed animal can be used to focus attention on something else when the urge to scratch is present. A diary can be useful when trying to identify patterns of behavior related to triggers of this condition. Flannel sheets may be irritating and should be avoided
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.
An infant has presented at the clinic with impetigo. Which organism usually causes impetigo in infants?
Staphylococcus aureus Explanation: Staphylococcus aureus is the most common cause of impetigo in infants. MRSA is a hospital-associated infection (HAI), group A beta hemolytic strep is seen in older children, and Escherichia coli is not frequently associated with impetigo.
In working with infants diagnosed with atopic dermatitis, the nurse anticipates that when these children are older they will likely have a tendency to have which disorder?
asthma Explanation: Infants who have atopic dermatitis (infantile eczema) tend to have allergic rhinitis or asthma later in life.
The nurse is presenting an in-service to a group of nurses who will be working in a dermatology clinic. One participant asks the nurse about a bacterial skin infection that she has seen in children that involves honey-colored crusted lesions. The nurse most likely is referring to:
impetigo. Explanation: Impetigo is a superficial bacterial skin infection. Impetigo in the newborn is usually bullous (blister-like, fluid filled); in the older child, the lesions are nonbullous and have a honey-colored, crusted appearance.
The client is scheduled to have potassium hydroxide testing performed. What will be needed to complete this test?
skin scrapings Explanation: Potassium hydroxide (KOH) testing is done to assess for the presence of a fungal infection. Skin scrapings are placed on a microscope slide and a drop of KOH 20% drop is added.
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." 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.
An adolescent is prescribed isotretinoin. Which statement indicates that the adolescent understands the necessary precautions associated with this drug?
"I have to make sure that I do not become pregnant while taking this drug." Explanation: Adolescent girls taking this drug who are sexually active must be on a pregnancy prevention program because the drug causes defects in fetal development. Monthly complete blood counts are required when taking isotretinoin. Isotretinoin is not associated with lung problems, so a chest radiograph is not necessary. Coal tar preparations are associated with staining of the clothing or fabrics. Isotretinoin does not stain clothes or fabrics.
A topical corticosteroid is prescribed for a child with contact dermatitis. Which statement by the mother would indicate the teaching was successful?
"I should not cover the area with plastic wrap after applying the cream." Explanation: An occlusive dressing such as plastic wrap over the area should not be used with topical corticosteroids. High-potency preparations should not be used. There is no need to shake topical corticosteroids. Benzoyl peroxide requires shaking before use. Applying the medication at night and rinsing off in the morning is used for coal tar preparations.
The nurse is caring for an infant with diaper dermatitis. Which statement by the child's parent would indicate a need for further education?
"I will use rubber pants over the cloth diapers in the future." Explanation: Prevention and management of diaper dermatitis include avoiding rubber pants, avoiding diaper wipes with fragrance or preservatives. Treatment of a rash includes allowing the child to go diaperless for a period of time each day and using a warm blow dryer on the area for 3 to 5 minutes.
The nurse instructor is reviewing the integumentary system during a presentation to a group of student nurses. Which statement made by the instructor is the most accurate regarding the integumentary system?
"The largest organ of the body helps regulate body temperature." Explanation: The skin is the largest organ of the body. The skin helps regulate the body temperature by heating and cooling. The sebaceous and sweat glands are not fully functional until middle childhood. The major role of the skin is to protect the organs and structures of the body against bacteria, chemicals, and injury. Excretion in the form of perspiration is also a function of the skin glands, called the sweat glands. Sebaceous glands in the skin secrete oils to lubricate the skin and hair. The integumentary system is in place at birth, but the system is immature. A function of the respiratory system is to distribute oxygen to body cells.
The clinic nurse is assessing a 12-year-old client. The client reports having dandruff and asks the nurse what can be done for it. Which response by the nurse is best?
"Wash your hair with a gentle shampoo daily." Explanation: In the older child and adolescent, a gentle shampoo should be used daily to control scaling caused by dandruff. A medicated shampoo may be indicated if shampooing with a gentle formula shampoo does not provide relief. Washing hair vigorously twice a day is not recommended. Warm baby oil is recommended for infants with cradle cap (seborrhea).
A pediatric client was brought to the emergency department by the parents after experiencing extensive urticaria following consumption of a seafood dinner. Upon discharge from the facility the nurse provided client teaching. Which statement by the parents indicate learning occurred?
"We need to get our child a medical alert bracelet as soon as possible in case this happens again." Explanation: A medical alert bracelet would identify the child's allergies in case the parents were not with the child or if the child was incapacitated following a reaction. Urticaria, commonly called hives, is a type I hypersensitivity reaction, which indicates a serious reaction. The child should not try to eat seafood again. Urticaria usually begins rapidly and may disappear in a few days or may take up to 6 to 8 weeks to resolve.
A parent calls the pediatric clinic and tells the nurse that the child has developed a large rash. Which question is most important for the nurse to ask the parent?
"What more can you tell me about the rash?" Explanation: It is most important for the nurse to find out more about the child's rash (the color, the location, is there any itching). This will help the nurse determine if this is a contact dermatitis or a bacterial or viral infection. Asking how long the child has had the rash, whether the child has had a change in behavior, and whether the child is current with immunizations are also appropriate. However, gathering more information about the rash itself is most important.
A school-aged child diagnosed with atopic dermatitis is having difficulty in school, and school performance is declining. The parent asks the nurse for interventions that can help improve the situation. How should the nurse respond? Select all that apply.
"You can help your child sleep better at night by giving the prescribed antihistamines." "The school nurse can apply skin moisturizers during the school day." "Talk with the child's teacher about work the child can do at home until flare-ups resolve." "Obtain an order from the health care provider for the child to rest in the nurse's office if too stressed."
The nurse is speaking with the mother of a child diagnosed with contact dermatitis from poison ivy. Which statement by the mother indicates a need for further education?
"As long as he takes a shower as soon as he gets inside, he shouldn't get this again." Explanation: Prevention of contact dermatitis from poison ivy, poison oak, or poison sumac includes wearing long pants and long sleeves on outings in the wood. If contact occurs, wash vigorously with soap and water within 10 minutes of contact. The plant's oil residue may be on clothes, pets, toys, and other objects, so these must be washed well with soap and water. Ivy Block is the only preventive treatment approved by the US FDA. It is applied to the skin before exposure.
The nurse is caring for a mom and her baby on a postpartum unit. The mom states she has received advice not to use baby powder on newborns. She asks the nurse if this is true, and if so, why. Which nurse response is correct?
"Baby powder should not be used on newborns due to the risk of aspiration upon application." Explanation: The use of baby powder containing "talc" (also known as "talcum powder") can cause accidental aspiration, pneumonia, and death. Aspiration is predominantly caused when the baby receives a "puff of smoke" when the powder is shaken from the container directly onto the baby's skin. In addition, the use of talcum powder is abrasive and is can contribute to the pathogenesis of diaper dermatitis.
An adolescent is prescribed isotretinoin. Which statement indicates that the adolescent understands the necessary precautions associated with this drug?
"I have to make sure that I do not become pregnant while taking this drug." Explanation: Adolescent girls taking this drug who are sexually active must be on a pregnancy prevention program because the drug causes defects in fetal development. Monthly complete blood counts are required when taking isotretinoin. Isotretinoin is not associated with lung problems, so a chest radiograph is not necessary. Coal tar preparations are associated with staining of the clothing or fabrics. Isotretinoin does not stain clothes or fabrics
The camp nurse is caring for a child who was bitten on the leg by a dangerous spider. The child is being taken to a health care provider. What is the most appropriate action for the nurse to do with this child?
Apply ice to the affected area. Explanation: Spider bites can cause serious illness if untreated. Bites of black widow spiders, brown recluse spiders, and scorpions demand medical attention. Applying ice to the affected area until medical care is obtained can slow absorption of the poison.
The nurse is caring for a child admitted with second-degree (partial-thickness) burns. What is most characteristic of this type of burn?
Blisters appear. Explanation: In first-degree (superficial) burns, the injury is only to the epidermis. The burns are very painful, red, and dry. In second-degree (partial-thickness) burns, the injury is to the epidermis and part of the dermis. These burns are painful, edematous, have a wet appearance and form blisters. In third-degree (full-thickness ) burns, the dermis, epidermis and hypodermis are all involved. There may or may not be pain. These burns are red and edematous and may have peeling, charred skin. Muscle damage can occur.
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. 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 camp nurse is caring for a child who was bitten on the leg by a dangerous spider. The child is being taken to a health care provider. What is the most appropriate action for the nurse to do with this child?
Spider bites can cause serious illness if untreated. Bites of black widow spiders, brown recluse spiders, and scorpions demand medical attention. Applying ice to the affected area until medical care is obtained can slow absorption of the poison.
An infant has presented at the clinic with impetigo. Which organism usually causes impetigo in infants?
Staphylococcus aureus Explanation: Staphylococcus aureus is the most common cause of impetigo in infants. MRSA is a hospital-associated infection (HAI), group A beta hemolytic strep is seen in older children, and Escherichia coli is not frequently associated with impetigo.
The nurse is caring for an infant who has impetigo and is hospitalized. Which nursing action is priority?
The nurse follows contact precautions. Explanation: Impetigo is highly contagious and can spread quickly. The nurse should follow contact (skin and wound) precautions, including wearing a cover gown and gloves. The nurse will soak the crusts with warm water, apply topical antibiotics, and apply elbow restraints, but these are not as high a priority as trying to prevent the spread of the infection by following contact precautions.
The nurse is educating a parent about the treatment for a child's tinea cruris. What medication class would the nurse include in the teaching plan?
antifungal Explanation: Tinea cruris is a fungal infection of the groin area. Treatment would include antifungals. Antihistamines are typically used for the treatment of hypersensitivity and allergy disorders. Corticosteroids are used in the treatment of allergies and dermatitis. Antibiotics would be used to treat bacterial infections of the skin.
An adolescent girl is going to be treated for a severe case of acne vulgaris. A pregnancy test should be done prior to the adolescent starting treatment with:
isotretinoin. Explanation: Isotretinoin is a drug used to treat cystic acne after at least 3 months of antibiotic therapy has not been successful. Isotretinoin is a pregnancy category X drug. It must not be used at all during pregnancy because of serious risk of fetal abnormalities. Tretinoin is used to treat severe acne vulgaris. Instruction for the use of this medication include using sunscreen. Benzoyl peroxide can be used for mild acne and can be used with topical antibiotics. Erythromycin is an antibiotic that has no pregnancy contraindications. It is used for many skin infections.
The nurse caring for a child with a skin allergy recognizes that the highest priority in the treatment for skin allergies is aimed at:
reducing swelling and relieving itching. Explanation: Treatment for skin allergies is aimed at reducing the swelling and relieving the itching. With swelling in various parts of the body, the child may have pain, nausea and vomiting, but reducing the swelling would prevent those symptoms from occurring.
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 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).
The parents of a child diagnosed with atopic dermatitis ask the nurse, "My child has a skin disorder. I don't understand why a complete blood count (CBC) was ordered?" What is the appropriate response by the nurse?
Eosinophils are a type of white blood cell that are often elevated with atopic dermatitis. These are part of the CBC and helps in making the diagnosis." Explanation: Atopic dermatitis is a type of allergic skin disorder, not a bacterial infection, in which the eosinophil count is often elevated. This is one test that will help in diagnosing the disorder. This explanation addresses the parents' question.
A child arrives at the emergency department with moderate hypothermia and frostbite. Which action would be most appropriate for the nurse to perform?
Place heating pads and warmed blankets on the trunk of the body initially. Explanation: With moderate hypothermia, the trunk of the client should be warmed first. Warming the extremities and trunk at the same time can cause a condition where the core body temperature drops due to the returning cold blood from the extremities. Dry heat should not be applied to a client with hypothermia and frostbite. Rubbing a frostbitten area may cause further damage and should be avoided.
The nurse is caring for a child with urticaria. What is the priority action?
assessing the child's airway and breathing and noting any wheezing or stridor Explanation: Urticaria is a type I hypersensitivity reaction. Therefore, the priority nursing assessment is to carefully assess airway and breathing, as hypersensitivity reactions may affect respiratory status. A detailed history, skin inspection, and evaluation of the hives are other appropriate assessments, but determining respiratory status is the priority.
The nurse is caring for a child with a tinea corporis infection involving several sites. Which information would be the most important for the nurse to include in the teaching plan for the parents?
finishing all prescribed oral medication, even after lesions fade Explanation: All prescribed oral medication should be finished in order to prevent reinfection. Socks should be removed after athletic events to allow skin to dry. Application of oils and petroleum jelly can cause more fungal growth. The child with tinea corporis may return to school after treatment has started.
A nurse is caring for a child with tinea pedis. Which assessment finding should the nurse expect?
red scaling rash on soles and between the toes Explanation: Tinea pedis presents with red scaling rash on soles, and between the toes. Tinea capitis presents with patches of scaling in the scalp with central hair loss and the risk of kerion development (inflamed boggy mass filled with pustules). Tinea cruris presents with erythema, scaling, maceration in the inguinal creases and inner thighs.
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 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).
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?
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
The nurse is conducting a primary survey of a 12-year-old child involved in a motor vehicle accident. Which assessment finding most concerns the nurse?
the presence of stridor Explanation: The nurse would suspect an airway injury since stridor is present. This would most concern the nurse as this indicates potential loss of airway. Burns on the hands, a broken tibia, and an inability to state own's name are concerning and require intervention. However, these are not indicative of an airway injury and not priority
The nurse is evaluating the parents' understanding of atopic dermatitis. Which statement shows their understanding?
"Flare-ups of lesions are not uncommon following therapy." Explanation: Atopic dermatitis is relapsing and remitting. It may recur when the child is re-exposed to the substance to which he or she is allergic, even following treatment. Approximately 30% of children with atopic dermatitis develop allergic rhinitis and asthma. It does not occur as a result of a strep infection. It is caused by an inflammatory process. The use of periodic hydrocortisone cream will not lead to kidney disease.
The parents of a child recently diagnosed with atopic dermatitis voice concern to the nurse that their child may develop asthma at some point. How should the nurse respond?
"I can understand your concern. We will closely monitor your child for asthma development." Explanation: Atopic dermatitis (eczema) is one of the disorders in the atopy family (along with asthma and allergic rhinitis). About 30% to 35% of children who have atopic dermatitis will also develop allergic rhinitis and/or asthma. Therefore, the child will be monitored for the development of asthma. Reference:
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.
An adolescent is to receive topical retinoid therapy for his moderately severe acne. The nurse would instruct the adolescent about which adverse effects? Select all that apply
burning photosensitivity dryness Explanation: Adverse effects associated with topical retinoid therapy include burning, dryness, and photosensitivity. Flu-like symptoms and headache are associated with topical immune modulators.
An adolescent experiencing contact dermatitis reports experiencing pruritis. What intervention will the nurse recommend to relieve the itching?
Bathe with a product that is oatmeal-based. Explanation: Pruritis is a common problem associated with contact dermatitis. By healing the lesions, the itching will subside. Bathing with oatmeal-based products will accomplish this healing. If the area is too involved, then products like a topical corticosteroid can be used. Calamine lotion is a product that can help with itching, but it is primarily used to dry out weeping lesions. Moisturizers can be applied to the irritated skin, but they must be free of fragrances and dyes. The area should not be covered but allowed to be exposed to air to aid in healing.
A 4-month-old infant is experiencing dermatitis in the diaper area. What treatments will be beneficial to this condition? Select all that apply.
Allow the diaper area to air dry. Apply petroleum jelly to the diaper area. Apply ointment with vitamin A to the diaper area. Use ointments containing zinc on the diaper area. Explanation: Diaper dermatitis starts as a flat red rash in the convex skin creases. It may appear red and shiny and may or may not also have papules. Keeping the diaper area clean and dry are key to healing. Air drying may promote healing. Topical products such as ointments or creams containing vitamins A, D, and E; zinc oxide; or petrolatum are helpful to provide a barrier to the skin. Talc powder is not recommended.
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.
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. 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 assessing a child who has had an open wound for the last 2 weeks with no signs of healing. The parents report they have been using over-the-counter antibiotic ointment with no signs of improvement. The child is active in football in the fall and the swim team in the winter. What disorder does the nurse suspect?
community acquired MRSA Explanation: Risk factors for community-acquired MRSA (CA-MRSA) are turf burns, towel sharing, participation in team sports, or attendance at day care or outdoor camps. The condition usually presents with a moderate to severe skin infection or with an infection that is not responding as expected to therapy. Impetigo is a readily recognizable skin rash infection. Staphylococcal scalded skin syndrome results from infection with S. aureus that produces a toxin, which then causes exfoliation, and it has abrupt onset. Folliculitis is an infection of a hair follicle.
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 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.
