Ch. 30 Wong's - Evolve NCLEX Practice Q's

Based on the nurse's knowledge of wounds and wound healing, what are factors that can delay or cause dysfunctional wound healing? (Select all that apply) A. Overweight B. Hypoxemia C. Hypervolemia D. Prolonged infection E. Corticosteroid therapy

A, C, E A. Overweight C. Hypervolemia E. Corticosteroid therapy Poor nutrition without proper protein and calorie intake affects healing more than being overweight itself. Hypovolemia, not hypervolemia, inhibits wound healing due to low circulating blood volume and oxygenation of tissues. Corticosteroid therapy or other immunocompromising therapy prevents macrophages from migrating to the site of injury, thus suppressing epithelialization. Hypoxemia makes tissues more susceptible to infection due to insufficient oxygenation. Prolonged infection affects the healing process and causes increased scarring.

The nurse is caring for a 12-year-old who sustained major burns when putting charcoal lighter on a campfire. The nurse observes that the child is "very brave" and appears to accept pain with little or no response. What is the most appropriate nursing action related to this? A. Request a psychological consultation. B. Ask the child why the child does not have pain. C. Praise the child for the ability to withstand pain. D. Encourage continued bravery as a coping strategy.

A. Request a psychological consultation. A psychological consultation will assist the child in verbalizing fears. This age group is very concerned with physical appearance. The psychologist can help integrate the issues the child is facing. It is likely that the child is having pain but not acknowledging the pain. Speaking with a psychologist might assist the child in relaying his or her fears and pain. If the child is feeling pain, the nurse should not praise the child for hiding the pain. The nurse should encourage the child to speak up during painful episodes so that the pain can be managed appropriately. Bravery may not be an effective coping strategy if the child is in severe pain.

What is the most important nursing consideration in the management of cellulitis? A. Application of Burow solution compresses B. Administration of oral or parenteral antibiotics C. Topical application of an antibiotic D. Incision and drainage of severe lesions

B. Administration of oral or parenteral antibiotics Oral or parenteral antibiotics are indicated depending on the extent of the cellulitis. Warm water compresses may be indicated for limited cellulitis. Antibiotics need to be administered systemically (orally or parenterally), not topically. If incision and drainage are implemented, there is a risk of spreading infection or making the lesion worse.

When teaching the adolescent about the management of acne, the nurse should include what instructions? A. Clean the face with an antibacterial soap twice each day. B. Clean the face gently with a mild soap once or twice each day. C. Avoid foods with a high-fat content such as French fries and chocolate. D. Express comedones by gentle squeezing; then cleanse with alcohol.

B. Clean the face gently with a mild soap once or twice each day. Cleansing the face with mild soap and water will remove surface dirt and oil, which is essential in the management of acne. Antibacterial soaps may be too drying when used in combination with topical medications and may exacerbate acne. No relationship has been established between food intake and acne. Squeezing the acne can break down the ductal walls of the lesions and cause the acne to worsen.

When giving instructions to a parent whose child has scabies, the school nurse should tell the parent to: A. treat all family members if symptoms develop. B. be prepared for symptoms to last 2 to 3 weeks. C. notify the practitioner so an antibiotic can be prescribed. D. carefully treat only those areas where there is a rash.

B. be prepared for symptoms to last 2 to 3 weeks. The mite responsible for scabies will most likely be killed with the administration of medications. It will take 2 to 3 weeks for the stratum corneum to heal. That is when the symptoms will abate. Only the affected child needs to be treated for scabies. A scabicide is used. Permethrin and lindane are currently used for topical administration. Permethrin is applied to all skin surfaces in the treatment of scabies.

During the rehabilitative phase of care, pressure dressings are primarily applied to burned areas to: A. relieve pain. B. decrease blood supply to scar. C. limit motion during the healing process. D. encourage healing through scar formation.

B. decrease blood supply to scar. Uniform pressure to the scar decreases the blood supply. The use of pressure garments serves to decrease the blood supply to the hypertrophic tissue. This is done to prevent scarring and contractures. The goal of the pressure dressing is to improve the appearance of scars by decreasing the blood supply to the area. Motion is encouraged because it prevents contractures. Movement should take place to the point of pain, but no further. The goal of the pressure dressing is to minimize the development of scar tissue.

A toddler has a deep laceration contaminated with dirt and sand. Before suturing, the nurse should irrigate the wound with: A. alcohol. B. normal saline. C. hydrogen peroxide. D. povidone-iodine.

B. normal saline. Normal saline is the only acceptable fluid for irrigation from the choices given above. The nurse should cleanse the wound with a forced stream of normal saline or water. Alcohol should not be used as an irrigation solution, because it is toxic to the wound. Hydrogen peroxide should not be used as an irrigation solution, because it is toxic to the wound. Povidone-iodine should not be used as an irrigation solution, because it is toxic to the wound

An occlusive dressing, is applied to a large abrasion. This is advantageous because the dressing will: A. provide an antiseptic for the wound. B. deliver vitamin C to wound. C. maintain a moist environment for healing. D. promote mechanical friction for healing.

C. maintain a moist environment for healing. Occlusive dressings such as Acuderm do not adhere to the wound site. They provide a moist wound surface and insulate the wound. Acuderm does not have antiseptic capabilities. Acuderm does not contain vitamin C. Acuderm protects against friction.

Enteral feedings are ordered for a young child with burns covering 40% of the total body surface area. The nurse should know that: A. oral feedings are contraindicated. B. enteral feedings must be stopped during painful procedures. C. paralytic ileus precludes use of enteral feedings. D. the feedings will be high in carbohydrate and low in protein.

C. paralytic ileus precludes use of enteral feedings. Enteral feedings can begin when the paralytic ileus resolves. Oral feedings are not contraindicated. Oral feedings are encouraged. Most children with burns are unable to consume sufficient calories by mouth, but every possible effort is made to encourage oral feeding. Enteral feedings can continue during procedures. A high-protein, high-calorie diet is recommended to compensate for the increased basal metabolic rate that occurs after a burn injury.

The school nurse is seeing a child who brought poison ivy to school in a leaf collection. The child says that only hands touched it. The most appropriate nursing action is to: A. apply Burow solution compresses immediately. B. soak hands in warm water. C. rinse hands in cold, running water. D. scrub hands thoroughly with antibacterial soap.

C. rinse hands in cold, running water. Washing the child's hands in cold running water is the recommended first action. Once contact has been made, it is desirable to flush the skin with cold running water within 15 minutes of exposure. This will neutralize the urushiol not yet bonded to the skin. Applying Burrow solution is effective for soothing the skin lesions once the dermatitis has begun. Cold running water, not warm water, is effective in removing the oil. The antibacterial soap removes protective skin oils and dilutes the urushiol, allowing it to spread.

When applying wet compresses or dressings to the skin, what should the nurse do? A. Apply the dressing so that the area is totally immobilized. B. Apply the dressing when it is saturated and dripping. C. Pour or syringe a new solution over a dressing that has become dry. D. Apply the desired solution on cotton gauze or soft cotton cloths, such as clean cloths.

D. Apply the desired solution on cotton gauze or soft cotton cloths, such as clean cloths. The desired solution should be applied to Kerlix gauze; soft cotton cloths; or strips from cloth diapers, sheets, or pillowcase material. The moist dressing should be laid flat on the area with an attempt to not restrict movement. After immersion in the solution, the dressings are wrung out to avoid dripping. The material should be moistened and then reapplied. When the solution dries, concentrated residue is left in the dressing. The addition of fluid may result in a more concentrated soak being placed on the sensitive tissue.

What is most descriptive of atopic dermatitis (eczema) in the infant? A. Eczema is worse in summer months. B. Eczema is worse in humid climates. C. Eczema is associated with upper respiratory tract infections. D. Eczema is associated with hereditary allergies.

D. Eczema is associated with hereditary allergies. The majority of children with atopic dermatitis have a family history of eczema, asthma, food allergies, or allergic rhinitis. This suggests a genetic predisposition. Atopic dermatitis worsens in fall and winter months. Eczema improves in humid climates. Eczema is associated with allergies.

Which factor promotes wound healing? A. Antiseptics B. Eschar formation C. Dry wound environment D. Moist, crust-free wound environment

D. Moist, crust-free wound environment This environment enhances the migration of epithelial cells across the wound and facilitates healing. Antiseptics, such as hydrogen peroxide and povidone-iodine, have a cytotoxic effect on healthy cells and little effect on controlling infections. Eschar formation does not promote wound healing. Eschar is burn crust or dead tissue that inhibits wound healing. A dry wound environment does not facilitate wound healing.

The school nurse is conducting an assessment for pediculosis capitis (head lice) on a group of school-age children. Which describes a child with a positive head check? A. Maculopapular lesions behind the ears B. White, flaky particles throughout the entire scalp area C. Lesions in the scalp extending from the hairline to the neck D. White sacs attached to the hair shafts in the occipital area

D. White sacs attached to the hair shafts in the occipital area Evidence of pediculosis capitis includes white sacs (nits) attached to the hair shafts and usually located in the occipital area. Lesions may be present from itching, but the positive sign is evidence of the nits. White flaky particles appear with dandruff, and lice nits must be distinguished from dandruff. Lesions may be present from itching, but the positive sign is evidence of the nits.

A child is being seen in the emergency department with multiple facial abrasions and lacerations. A combination agent containing lidocaine, adrenaline, and tetracaine (LAT gel) is applied topically to the wounds. The purpose of this combination therapy is to: A. cleanse the wound. B. promote scab formation. C. prevent infection of the wound. D. provide anesthesia to the wound.

D. provide anesthesia to the wound. The combination of lidocaine, adrenaline, and tetracaine provides anesthesia within 10 to 15 minutes of application. LAT does not have a cleansing effect. LAT has no effect on scab formation. LAT has no antibacterial effect.

A nurse should explain that ringworm is: A. a noncontagious disorder. B. a sign of uncleanliness. C. expected to resolve spontaneously. D. spread by direct and indirect contact.

D. spread by direct and indirect contact. Ringworm is spread by both direct and indirect contact. Children should wear protective caps at night to avoid transfer of ringworm to bedding. Ringworm is an infectious disorder. Because ringworm is easily transmitted, it is not a sign of uncleanliness. It can be acquired from theater seats or gym mats and by animal-to-human transmission. The drug griseofulvin (Fulvicin) is indicated for a prolonged course, possibly several months.