Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder

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)? A. splattering patterns B. splash patterns C. nonuniform pattern D. stocking-glove pattern on hands or feet

D. stocking-glove pattern on hands or feet 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 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? A. "Has she been exposed to poison ivy?" B. "Tell me about your family history of allergies." C. "Do you change her diapers regularly?" D. "Does she wear sleepers with metal snaps?"

D. "Does she wear sleepers with metal snaps?" 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 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? A. "The complete blood count is a routine test used anytime there is an abnormal condition in the body." B. "This test will help in determining the type of bacteria that is causing this infection." C. "This is just another tool to help rule out any other disorders that can be causing this skin disorder. There will be other lab tests ordered as well." D. "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."

D. "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." 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.

The nurse is interviewing the mother of a 6-month-old being seen at a well-child visit. The mother reports she has used an over-the-counter topical ointment intended for adults on her child for a skin rash. What is the most appropriate response by the nurse? A. "Children have thin skin and can absorb medications differently than adults." B. "Why did you do that instead of contacting your doctor?" C. "How often do you use this medication?" D. "This is dangerous so please do not do this again."

A. "Children have thin skin and can absorb medications differently than adults." Children have thinner skin than adults. They will absorb topical medications more rapidly than adults. Medications concentrated for adults should not be used on children. It is important to explain this to the parent. It is confrontational to tell her this is dangerous or to tell her to contact the physician. The frequency of use is information that should be obtained but the education is most important in this scenario.

An 8-year-old child requires wet dressings four times a day as treatment for a skin disorder. What would be most important for the nurse to do? A. Elevate the area after performing the dressing change. B. Ensure that the temperature of the solution is 120°F (48.9°C). C. Premedicate the child before changing the dressing. D. Use a fragrance-free, dye-free soap to clean the wound.

C. Premedicate the child before changing the dressing. Premedicating the child before changing the dressing is crucial to providing atraumatic care. Elevating the area may or may not be appropriate depending on the problem and its location. A temperature of 120°F (48.9°C) is the recommended maximal hot water heater temperature. The solution for a wet dressing should not be this hot. There is no indication that the wound should be cleaned.

The nurse is caring for a child admitted with second-degree (partial-thickness) burns. What is most characteristic of this type of burn? A. muscle damage occurs B. pain is minimal C. skin is red and edematous D. blisters appear

D. blisters appear 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.

The nurse is collecting data from a 14-year-old female and her mother who have come to the clinic for a check-up. The child's mother reports the teen has had hives intermittently for the past two months. What is the priority action for this client? A. determine the underlying cause B. Encourage the mother to purchase over-the-counter topical ointments to keep on hand in the event of another episode. C. Encourage the family to speak to the physician about prescribing topical steroids. D. Discuss home remedies to manage the skin condition.

A. determine the underlying cause Urticaria, commonly called hives, is a type I hypersensitivity reaction caused by an immunologically mediated antigen-antibody response of histamine release from mast cells. Urticaria usually begins rapidly and may disappear in a few days or may take up to 6 to 8 weeks to resolve. The most common causes of this reaction are foods, drugs, animal stings, infections, environmental stimuli (e.g., heat, cold, sun, tight clothes), and stress. The priority is to determine the underlying cause. Over-the-counter topical agents, prescription strength medications, and home remedies may be discussed and employed but are not of greatest importance.

A 6-year-old child is diagnosed with tinea capitis and treatment is initiated. The nurse instructs the parents to have the child return to school within which time frame? A. 1 week B. 5 days C. 24 hours D. 72 hours

A. 1 week Once treatment is initiated for tinea capitis, the child can return to school or day care after 1 week.

The nurse is examining a child for indications of frostbite and notes blistering with erythema and edema. The nurse notes which degree of frostbite? A. second-degree frostbite B. fourth-degree frostbite C. third- degree frostbite D. first-degree frostbite

A. second-degree frostbite Second-degree frostbite demonstrates blistering with erythema and edema. First-degree frostbite results in superficial white plaques with surrounding erythema. In third-degree frostbite, the nurse would note hemorrhagic blisters that would progress to tissue necrosis and sloughing when the fourth degree is reached.

An infant has presented at the clinic with impetigo. Which organism usually causes impetigo in infants? A. Methicillin-resistant Staphylococcus aureus (MRSA) B. Staphylococcus aureus C. Escherichia coli D. Group A beta hemolytic strep

B. Staphylococcus aureus 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.

A 10-year-old has been bitten on the lower posterior arm by a dog, requiring several stitches. The child was just admitted to the hospital for 3 days of antibiotic therapy. When developing the care plan, the nurse identifies which nursing diagnoses as being the top 2 priorities? A. Knowledge deficit regarding care of wound B. risk of infection C. impaired skin integrity D. disturbed body image E. risk for fluid volume deficit

B. risk of infection C. impaired skin integrity The wound was not a clean wound, such as a surgical wound, so risk for infection would be a top priority. The child has impaired skin integrity from the wound and from the IV. Since the wound is new and on the arm the nursing diagnosis disturbed body image would not be a top 2 priority at this time. It is unlikely that a great deal of fluid has been lost from this wound. Knowledge deficit of wound care would not be a top 2 priority at this time, but would be an important nursing diagnosis to address later.

A child is admitted to the acute care facility with a burn injury. The nurse would check the child's immunization status, specifically for which of the following? A. meningitis B. tetanus C. diphtheria D. pertussis

B. tetanus For any burn, 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, because anaerobic and aerobic bacteria can grow at the interface between burned and healthy tissue. Pertussis, diphtheria, and meningitis are not important immunizations to check for with a burn patient.

The nurse is caring for a child with a prescription for PO prednisone. Which statement by the child's mother would indicate a need for further education? A. "My child should take the entire prescription as prescribed by the health care provider." B. "Since my child has type 1 diabetes, I will need to monitor my child's blood sugar levels closely while on this medication." C. "I will give it to my child at least 1 hour before all meals." D. "I will have to watch my child closely for signs of infection."

C. "I will give it to my child at least 1 hour before all meals." Systemic corticosteroids such as prednisone should be administered with food to decrease gastrointestinal upset. These medications may mask signs of infection. This medication may increase blood sugar levels. Corticosteroid doses should be tapered and should not be stopped abruptly.

What accurately depicts the hemodynamic changes that occur in the body w/in the first 24-48 hrs after a burn? A. Hematocrit and white blood cell (WBC) counts decrease. B. Hemoglobin and white blood cell (WBC) counts decrease. C. Hematocrit increases and white blood cell (WBC) count decreases. D. Hematocrit and white blood cell (WBC) counts increase.

D. Hematocrit and white blood cell (WBC) counts increase. In the first 24 to 48 hours after a burn, the hematocrit will often be elevated secondary to fluid loss and the WBC count may also be elevated as an acute-phase reaction, which later could indicate infection.

The nurse is caring for a 2-year-old boy with a burn. What finding would warrant referral to a burn unit? A. a superficial or first-degree burn on the hand B. a superficial or first-degree burn on the upper arm C. a superficial or first-degree burn on the chest D. a chemical burn

D. a chemical burn According to the American Burn Association, chemical burns warrant referral to a burn unit. A partial-thickness or second-degree burn greater than 10% of the body surface area would warrant a referral to a burn unit. A superficial or first-degree burn on the chest or hands does not warrant a referral to a burn unit.

The nurse is caring for a child with urticaria. What is the priority action? A. obtaining a detailed history of new foods, medications, stress, or changes in environment B. assessing the child's airway and breathing and noting any wheezing or stridor C. Noting whether hives are pruritic, blanch when pressed, or are migrating D. inspecting the skin and noting evidence of raised, edematous hives anywhere on the body

B. assessing the child's airway and breathing and noting any wheezing or stridor 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.

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

A. Provide around-the-clock pain medication as soon as pain is reported. 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 child is hospitalized with a diagnosis of severe cellulitis. The nurse is preparing the family for discharge. Which instruction is most important for the nurse to convey to the family? A. monitor for signs of worsening condition B. keep f/u appts C. complete the prescribed antibiotics D. perform proper hand hygiene

C. complete the prescribed antibiotics The instruction that is most important for the nurse to convey is to complete the prescribed course of antibiotics. Many times, once the child feels better, the parent stops the medication; this action, though, can cause a rebound infection. Instructing the family to keep follow-up appointments, perform good hand hygiene, and look out for signs of worsening condition are all appropriate, but the most important instruction is to make sure the child completes the course of antibiotics.

The nurse is discussing skin disorders with a group of caregivers. Which caregiver statement indicates an understanding of tinea capitis? A. "My husband had that once and his groin itched so much." B. "I always tell my daughter to use her own hairbrush." C. "My son got that infection when he was at the swimming pool." D. "That is an infection that you get under your fingernails."

B. "I always tell my daughter to use her own hairbrush." Ringworm of the scalp is called tinea capitis or tinea tonsurans. The most common cause is infection with Microsporum audouinii, which is transmitted from person to person through combs, towels, hats, barber scissors, or direct contact. A less common type, Microsporum canis, is transmitted from animal to child.

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? A. soak the child in a colloidal bath B. provide diversional activities C. turn the child Q2 D. administer diphenhydramine

D. administer diphenhydramine 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.

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? A. "I guess my mom was right; she always put ice on our burns when we were kids." B. "For a superficial burn, I can cover it with a clean nonadherent dressing." C. "Mild soap can be used to clean a superficial burn." D. "If my child has a superficial burn, I will run cool water over it."

A. "I guess my mom was right; she always put ice on our burns when we were kids." 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 dermatologist treating a 16-year-old girl with a history of severe acne has ordered a pregnancy test so she can be started on a course of isotretinoin. The teen's caregiver has said that her daughter is a virgin and she refuses to allow her to have the required pregnancy testing. What would be the best action for the nurse to take? A. Arrange for the daughter to have the pregnancy testing without the caregiver's knowledge. B. Acknowledge the caregiver's discomfort about the pregnancy testing but encourage her to allow the daughter to have the testing so that she can use the medication. C. Speak with the teen alone to ask her if she is sexually active. If she says she is not sexually active, let the provider know that it is okay to write the prescription. D. Have the caregiver sign a permission form acknowledging that the girl has been given the drug without pregnancy testing.

B. Acknowledge the caregiver's discomfort about the pregnancy testing but encourage her to allow the daughter to have the testing so that she can use the medication. Isotretinoin is a pregnancy category X drug: It must not be used at all during pregnancy because of serious risk of fetal abnormalities. To rule out pregnancy, a urine test is done before beginning treatment. For the sexually active adolescent girl, an effective form of contraception must be used for a month before beginning and during isotretinoin therapy. The risk to the fetus, should pregnancy occur, should be discussed with the girl whether she is sexually active or not.

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? A. impetigo B. staphylococcal scalded skin syndrome C. community acquired MRSA D. folliculitis

C. community acquired MRSA 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 2-month-old infant. The parent asks if it is okay to use a sunscreen lotion made for children. Which response by the nurse would be most accurate? A. "Sunscreen is not recommended until 6 months of age. Use light clothing and a hat to completely cover the child when in the sun." B. "Put plenty of children's sunscreen on the infant at least 15 minutes before going outdoors, then reapply every 3 to 4 hours." C. "It is okay to use a children's sunscreen as long as you avoid the face." D. "You should not bring your infant into sunny locations."

A. "Sunscreen is not recommended until 6 months of age. Use light clothing and a hat to completely cover the child when in the sun."

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? A. Tell the parent that the infant will need to see an endocrine specialist about the problem. B. Make a note to inform the health care provider of the parent's concern. C. Explain that this normal mechanism keeps the infant from losing too much water through the skin. D. Explain that this is because an infant's temperature normally runs lower than an adult's.

C. Explain that this normal mechanism keeps the infant from losing too much water through the skin. 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 nurse is reviewing a plan of care for a 5-year-old child hospitalized with severe burns. Due to systemic changes that occur secondary to the burn injuries, what intervention(s) related to nutrition should the nurse expect to implement? Select all that apply. A. start the child on a low-protein diet B. administer a PPI C. initiate TPN D. offer the child's favorite foods E. insert NG tube

B. administer a PPI C. initiate TPN D. offer the child's favorite foods E. insert NG tube Systemic changes related to nutrition that can occur with severe burn injuries include a paralytic ileus and anorexia. The nurse should expect to insert a nasogastric tube in the presence of an ileus. Administration of a proton pump inhibitor would prevent the occurrence of a stress ulcer (also known as a curling ulcer). If the child is able to take food by mouth, to promote adequate nutrition, it is important to offer the child's favorite foods. If all else fails, total parenteral nutrition would be started to ensure the child received adequate nutrition. A high-protein diet promotes healing, not a low-protein one.

The nurse is collecting data on a child with a diagnosis of atopic dermatitis. While interviewing the caregiver, the nurse will direct questions to the caregiver recognizing that which common allergens are involved in eczema? Select all that apply. A. cotton B. animal dander C. nylon D. oatmeal E. red meat F. cow's milk

B. animal dander C. nylon F. cow's milk Atopic dermatitis causes extreme itching and reddened, inflamed skin. It is caused by a reaction to an antigen. It is relapsing and remitting. The most common food allergens are eggs, wheat, milk, and peanuts. There are also large reactions to tomato juice and orange juice. The most common environmental factors are mold, dust mites, and cat dander. Wool, nylon, and plastic can also cause reactions. It is recommended the child sleep in loose cotton clothing and cotton bedsheets. Wool tends to cause more itching and holds in the heat. Nylon is synthetically made and the child can have a reaction to the materials used. Nylon clothing also tends to hold in heat. Red meat is not known to cause reactions.

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? A. Explain that frequent diaper changes will prevent diaper rash. B. Tell the parent that he or she has used too much ointment. C. Commend the parent on addressing the infant's diaper rash. D. Provide instruction on how to care for a diaper rash.

D. Provide instruction on how to care for a diaper rash. 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.

A 30-month-old child has been discharged from the hospital after receiving treatment for second-degree (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? A. make an appt for the parent to bring the child to the clinic for evaluation B. tell the parent to allow the child to nurse as much as the child wants C. explain that children who have had a serious injury sometimes exhibit regressive behavior D. encourage the parent to explain to the child that he or she must drink from the cup

C. explain that children who have had a serious injury sometimes exhibit regressive behavior 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.

An adolescent is prescribed isotretinoin. Which statement indicates that the adolescent understands the necessary precautions associated with this drug? A. "I'm going to have to have a blood count done every couple of months." B. "I have to make sure that I do not become pregnant while taking this drug." C. "This drug can affect my lungs so I need a chest radiograph done first." D. "The drug might cause staining of my clothing."

B. "I have to make sure that I do not become pregnant while taking this drug." 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.

Which assessment finding by the nurse would warrant immediate action? A. A child with impetigo has honey-colored drainage noted on the skin area. B. A child has a red, warm, edematous area over an old spider bite. C. A child with cellulitis has a temporal temperature of 101°F (38.3°C). D. A child with periorbital cellulitis reports changes in vision and pain with eye movement.

D. A child with periorbital cellulitis reports changes in vision and pain with eye movement. In a child with periorbital cellulitis, the nurse musty notify the health care provider immediately if signs of progression to orbital cellulitis occur, such as conjunctival redness, change in vision, pain with eye movement, eye muscle weakness or paralysis, or proptosis. This assessment finding warrants immediate action. In nonbullous impetigo, a honey-colored exudate when the vesicles or pustules rupture may be noted on the skin. This assessment finding would be expected. A localized cellulitis will present with erythema, pain, edema, and warmth at the site of the skin disruption (such as a cut or spider bite). This assessment finding warrants further follow-up but not immediate attention. Fever may occur with bullous impetigo or cellulitis and is common with scalded skin syndrome; therefore, this assessment finding also warrants further, but not immediate, follow-up.