Tissue Integrity & Incontinence Questions

The school nurse is conducting pediculosis capitis (head lice) assessments. Which finding indicates a child has a "positive" head check? 1. Maculopapular lesions behind the ears 2. Lesions in the scalp that extend to the hairline or neck 3. White flaky particles throughout the entire scalp region 4. White sacs attached to the hair shafts in the occipital area

4. White sacs attached to the hair shafts in the occipital area

What should the nurse teach the client to do to prevent stress incontinence? Select all that apply. 1. Use techniques that strengthen the sphincter and structural supports of the bladder, such as Kegel exercises. 2. Avoid dietary irritants (e.g., caffeine, alcoholic beverages). 3. Not to laugh when in social gatherings. 4. Carry an extra incontinence pad when away from home. 5. Obtain a fluid intake of 500 mL/ day.

1, 2. Laughing may be a part of one's socialization, so it should not be discouraged. In non-restricted clients, a fluid intake of at least 2 to 3 L/ day is encouraged; clients with stress incontinence may reduce their fluid intake to avoid incontinence at the risk of developing dehydration and urinary tract infections. Establishing a voiding schedule would be more effective in the prevention of stress incontinence rather than carrying incontinence pads. Dietary irritants and natural diuretics, such as caffeine and alcoholic beverages, may increase stress incontinence. Kegel exercises strengthen the sphincter and structural supports of the bladder.

Which of the following interventions would be most appropriate for a client who has urge incontinence? 1. Have the client urinate on a timed schedule. 2. Provide a bedside commode. 3. Administer prophylactic antibiotics. 4. Teach the client intermittent self-catheterization technique.

1. Instructing the client to void at regularly scheduled intervals can help decrease the frequency of incontinence episodes. Providing a bedside commode does not decrease the number of incontinence episodes and does not help the client who leads an active lifestyle. Infections are not a common cause of urge incontinence, so antibiotics are not an appropriate treatment. Intermittent self-catheterization is appropriate for overflow or reflux incontinence, but not urge incontinence, because it does not treat the underlying cause.

The mother of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin? 1. Fine grayish red lines 2. Purple-colored lesions 3. Thick, honey-colored crusts 4. Clusters of fluid-filled vesicles

1. Fine grayish red lines

The clinic nurse is reviewing the health care provider's prescription for a child who has been diagnosed with scabies. Lindane has been prescribed for the child. The nurse questions the prescription if which is noted in the child's record? 1. The child is 18 months old. 2. The child is being bottle-fed. 3. A sibling is using lindane for the treatment of scabies. 4. The child has a history of frequent respiratory infections.

1. The child is 18 months old.

The nurse is developing a teaching plan for a client with stress incontinence. Which of the following instructions should be included? 1. Avoid activities that are stressful and upsetting. 2. Avoid caffeine and alcohol. 3. Do not wear a girdle. 4. Limit physical exertion.

2. Clients with stress incontinence are encouraged to avoid substances, such as caffeine and alcohol, that are bladder irritants. Emotional stressors do not cause stress incontinence. It is most commonly caused by relaxed pelvic musculature. Wearing girdles is not contraindicated. Although clients may want to limit physical exertion to avoid incontinence episodes, they should be encouraged to seek treatment instead of limiting their activities.

A client has stress incontinence. Which of the following data from the client's history contributes to the client's incontinence? 1. The client's intake of 2 to 3 L of fluid per day. 2. The client's history of three full-term pregnancies. 3. The client's age of 45 years. 4. The client's history of competitive swimming.

2. The history of three pregnancies is most likely the cause of the client's current episodes of stress incontinence. The client's fluid intake, age, or history of swimming would not create an increase in intra-abdominal pressure.

The nurse is verifying that a mother understands how to care for her infant who has thrush. Which comment by the mother would indicate that further teaching is indicated? 1. "I will feed my baby before I apply the medication." 2. "I can put the medication in my son's bottle for him to drink." 3. "I need to thoroughly clean all bottles and nipples after every use." 4. "I will slowly put the medication in each cheek of my baby's mouth."

2. "I can put the medication in my son's bottle for him to drink."

The nurse is collecting data on a child brought to the health care clinic by the mother with a 1-week-old cat scratch. While assessing the scratch the nurse notes redness, heat, swelling, and red streaking surrounding the area. The child states that the scratch hurts. Cellulitis is diagnosed. When providing home care instructions, which statement by the mother indicates a need for further teaching? 1. "The child should rest in bed." 2. "I will apply cool moist soaks every 4 hours." 3. "I should take the child's temperature and watch for a fever." 4. "The affected extremity should be elevated and immobilized."

2. "I will apply cool moist soaks every 4 hours.

The nurse is developing a plan of care for a 10-year-old girl with an exacerbation of eczema. Which problem should be addressed in the care for this child? 1. The client is at risk for infection related to viral lesions. 2. The client is at risk for infection related to scratching of pruritic lesions. 3. The client may have poor nutritional intake related to throat edema and mouth ulcers. 4. The client may have a negative body image related to the presence of thick, white crusty plaques over the elbows and knees.

2. The client is at risk for infection related to scratching of pruritic lesions.

A client has urge incontinence. When obtaining the health history, the nurse should ask if the client has: 1. Inability to empty the bladder. 2. Loss of urine when coughing. 3. Involuntary urination with minimal warning. 4. Frequent dribbling of urine.

3. A characteristic of urge incontinence is involuntary urination with little or no warning. The inability to empty the bladder is urine retention. Loss of urine when coughing occurs with stress incontinence. Frequent dribbling of urine is common in male clients after some types of prostate surgery or may occur in women after the development of a vesicovaginal or urethrovaginal fistula.

A nurse reinforces instructions to the mother of a child diagnosed with pediculosis (head lice). Permethrin 1% (Nix) has been prescribed. Which statement by the mother regarding the use of the medication indicates a need for further teaching? 1. "I need to purchase the medication from the pharmacy." 2. "After rinsing out the medication, I need to avoid washing my child's hair for 24 hours." 3. "I need to shampoo my child's hair, apply the medication, and leave the medication on for 24 hours." 4. "I need to shampoo my child's hair, apply the medication, and leave it on for 10 minutes and then rinse it out."

3. "I need to shampoo my child's hair, apply the medication, and leave the medication on for 24 hours."

The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction? 1. "It is extremely contagious." 2. "It is most common in humid weather." 3. "Lesions most often are located on the arms and chest." 4. "It might show up in an area of broken skin, such as an insect bite."

3. "Lesions most often are located on the arms and chest."

The primary goal of nursing care for a client with stress incontinence is to: 1. Help the client adjust to the frequent episodes of incontinence. 2. Eliminate all episodes of incontinence. 3. Prevent the development of urinary tract infections. 4. Decrease the number of incontinence episodes.

4. The primary goal of nursing care is to decrease the number of incontinence episodes and the amount of urine expressed in an episode. Behavioral interventions (e.g., diet and exercise) and medications are the nonsurgical management methods used to treat stress incontinence. Without surgical intervention, it may not be possible to eliminate all episodes of incontinence. Helping the client adjust to the incontinence is not treating the problem. Clients with stress incontinence are not prone to the development of urinary tract infection.

The nurse is counseling the young mother of a small child recently diagnosed with impetigo. The nurse should make which statement that provides the best information about impetigo? 1. "The main treatment while your daughter has impetigo will be to force fluids." 2. "Your daughter probably caught the impetigo because you don't wash her hands enough." 3. "There is no risk of passing impetigo to the other children once you begin the prescribed antibiotics." 4. "You will need to prevent any of the fluid from the blisters around your daughter's mouth from coming into contact with your other children, especially if they already have skin injuries."

4. "You will need to prevent any of the fluid from the blisters around your daughter's mouth from coming into contact with your other children, especially if they already have skin injuries."

A topical corticosteroid is prescribed by a health care provider for a child with atopic dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream? 1. Apply the cream over the entire body. 2. Apply a thick layer of cream to affected areas only. 3. Avoid cleansing the area before application of the cream. 4. Apply a thin layer of cream and rub it into the area thoroughly.

4. Apply a thin layer of cream and rub it into the area thoroughly.

Permethrin (Elimite) is prescribed for a child with a diagnosis of scabies. The nurse should give which instruction to the parents regarding the use of this treatment? 1. Apply the lotion to areas of the rash only. 2. Apply the lotion and leave it on for 6 hours. 3. Avoid putting clothes on the child over the lotion. 4. Apply the lotion to cool, dry skin at least 30 minutes after bathing.

4. Apply the lotion to cool, dry skin at least 30 minutes after bathing.

Nursing care of the infant with eczema should focus on which action as a priority nursing intervention? 1. Keeping the infant content 2. Maintaining adequate nutrition 3. Applying antibiotic ointment to lesions 4. Preventing secondary infection of the lesions

4. Preventing secondary infection of the lesions

The nurse is providing a yearly summer educational session to parents in a local community. The topic of the session is prevention and treatment measures for poison ivy. The nurse instructs the parents that if the child comes into contact with poison ivy to take which action? 1. Immediately report to the emergency department. 2. Avoid becoming concerned if a rash is not noted on the skin. 3. Apply calamine lotion immediately to the exposed skin areas. 4. Shower the child immediately, lathering and rinsing the exposed skin several times.

4. Shower the child immediately, lathering and rinsing the exposed skin several times.