Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder
A 6-year-old child has been diagnosed with tinea capitis. Which statement(s) by the parents demonstrate the need for further teaching? Select all that apply. - "We should wash sheets and towels in hot water to decrease the spread to other family members." - "Our child can return to school 24 hours after taking the antifungal medication." - "We can use selenium sulfide shampoo to decrease contagiousness." - "We should not expect our child to suffer hair loss." - "We should have our child take the prescribed antifungal medication until symptoms have resolved."
Answer: - "Our child can return to school 24 hours after taking the antifungal medication." - "We should not expect our child to suffer hair loss." - "We should have our child take the prescribed antifungal medication until symptoms have resolved." Rationale: Tinea capitis is a fungal infection of the scalp. The condition is contagious. Sheets and towels should be laundered in hot water to prevent the spread of the infection. Hair loss should be expected, and regrowth should occur in 3 to 12 months. The medication therapy should be completed, not just taken until symptoms have resolved. The child should not attend school or day care for 1 week after treatment is initiated.
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? A.) blood pressure 100/56 mm Hg B.) temperature 100.5°F (38.1°C) C.) O2 saturation 96% (0.96) on 2L D.) Pain level 8 out of 10
Answer: B.) temperature 100.5°F (38.1°C)
The nurse is teaching parents about the care of diaper rash. The nurse would be concerned about the parents' level of understanding if they made which statement? A.) "I need to wash and rinse clothes thoroughly to be sure all of the detergent is washed out." B.) "I should not overdress the infant." C.) "I should only use ointments and creams as instructed by the health care provider." D.) "I should be certain to use fabric softener in the care of the infant's clothes."
Answer: D.) "I should be certain to use fabric softener in the care of the infant's clothes."
An adolescent is diagnosed with psoriasis. After speaking with the nurse about treatment options suggested by the primary health care provider, the adolescent states, "Since ultraviolet rays help, I am going to buy a tanning package so I can tan year round." How will the nurse respond? A.) "Year round tanning is not what your health care provider intended. Tanning puts you at high risk for skin cancer and other problems." B.) "I do not think the health care provider meant for you to tan year round. Is that exactly what your health care provider said to you?" C.) "Be sure to not get burned while you are tanning. Sunburns can significantly increase your chances of getting skin cancer." D.) "I know it must be tempting, especially at your age. However, please understand that a tanning salon is not a good option for your health."
Answer: A.) "Year round tanning is not what your health care provider intended. Tanning puts you at high risk for skin cancer and other problems."
The nurse is evaluating the parents' understanding of atopic dermatitis. Which statement shows their understanding? A.) "Atopic dermatitis turns to asthma later in life." B.) "Hydrocortisone cream may lead to kidney disease." C.) "Flare-ups of lesions are not uncommon following therapy." D.) "Atopic dermatitis follows a streptococcal infection."
Answer: C.) "Flare-ups of lesions are not uncommon following therapy." Rationale: 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.
A health care provider has prescribed cephalexin 30 mg/kg PO daily in 4 divided doses for a child diagnosed with impetigo. The child weighs 30 lb (14 kg). How many milligrams should the child receive each day?
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The nurse is caring for a 13-year-old girl with acne vulgaris and is teaching the girl about skin care. Which response by the girl indicates a need for further teaching? A.) "I should avoid eating any kind of chocolate." B.) "I must use my medicine daily so that it will work." C.) "I should use a humectant moisturizer." D.) "It is best to avoid hats and headbands."
Answer: A.) "I should avoid eating any kind of chocolate." Rationale: Ingestion of chocolate has not been proven to contribute to the incidence or severity of acne. Adhering to the medication regimen, using a humectant moisturizer, and avoiding hats and headbands would be appropriate.
A topical corticosteroid is prescribed for a child with contact dermatitis. Which statement by the mother would indicate the teaching was successful? A.) "I should not cover the area with plastic wrap after applying the cream." B.) "I should use the highest-potency steroid cream I can find." C.) "I need to shake the preparation before using it." D.) "I should apply the medicine at bedtime and rinse it off in the morning."
Answer: A.) "I should not cover the area with plastic wrap after applying the cream."
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.) Administer diphenhydramine. B.) Turn the child every 2 hours. C.) Soak the child in a colloidal bath. D.) Provide diversional activities.
Answer: A.) Administer diphenhydramine.
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? A.) Provide around the clock pain medication. B.) Administer analgesics when the child reports pain. C.) Provide diversional activities for the client. D.) Provide an egg crate mattress or gel mattress for the client to lie upon.
Answer: A.) Provide around the clock pain medication.
The nurse is caring for a client brought to a pediatric clinic for swelling in the lower extremities with reddened skin that has undefined borders and pits slightly when pressed. What is the most likely diagnosis of the client's skin alteration? A.) cellulitis B.) impetigo C.) staphylococcal scalded skin syndrome D.) cat scratch disease
Answer: A.) cellulitis
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? A.) Administer pain medication. B.) Apply ice to the affected area. C.) Splint the leg. D.) Briskly scrub the site.
Answer: B.) Apply ice to the affected area.
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.) Make a note to inform the health care provider of the parent's concern. B.) Explain that this normal mechanism keeps the infant from losing too much water through the skin. C.) Tell the parent that the infant will need to see an endocrine specialist about the problem. D.) Explain that this is because an infant's temperature normally runs lower than an adult's.
Answer: B.) Explain that this normal mechanism keeps the infant from losing too much water through the skin.
A child has an order for an erythrocyte sedimentation rate (ESR). The child's mother asks what the purpose of the test is. What is the best response by the nurse? A.) "This is a test to determine if your child has a skin infection." B.) "This test will tell if your child has allergies." C.) "This test will tell if your child has an infection or inflammation somewhere in their body." D.) "This test will tell if your child has a fungus somewhere in their body."
Answer: C.) "This test will tell if your child has an infection or inflammation somewhere in their body."
The nurse is collecting data on a child admitted to the burn unit with a partial-thickness or second-degree burn. What is most accurate regarding this type of burn? A.) The nerve endings are destroyed. B.) The child will have minimal pain. C.) The child will likely have blisters. D.) There is no destruction of tissue.
Answer: C.) The child will likely have blisters.
The client is scheduled to have potassium hydroxide testing performed. What will be needed to complete this test? A.) a blood specimen B.) a urine specimen C.) skin scrapings D.) a strand of hair with the root attached
Answer: C.) skin scrapings
The nurse is caring for a 2-year-old child who experienced burns to the left upper arm, left thigh, left leg, head, and neck. The nurse calculates this to represent what percentage of total body surface area (BSA) burned? Record your answer using one decimal place.
34.5 Rationale: The calculation of BSA is as follows: Left upper arm = 4%, Left leg and thigh = 11.5%, Head = 17%, Neck = 2%. Added up, these values equal 34.5%.
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.) Commend the parent on addressing the infant's diaper rash. B.) Explain that frequent diaper changes will prevent diaper rash. C.) Tell the parent that he or she has used too much ointment. D.) Provide instruction on how to care for a diaper rash.
Answer: D.) Provide instruction on how to care for a diaper rash.
When reviewing bathing habits for a child with dermatitis, which statements by the child's mother indicates the need for further instruction? Select all that apply. - "When drying the skin I should pat instead of rubbing it." - "Antibacterial soap will be helpful in preventing infections at the site of the rash." - "It is important to avoid soaps with dyes and perfumes." - "I should apply the topical ointments after bathing." - "I should use the warmest water my child can tolerate during the bath."
Answer: - "Antibacterial soap will be helpful in preventing infections at the site of the rash." - "I should use the warmest water my child can tolerate during the bath."
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.) "If my child has a superficial burn, I will run cool water over it." C.) "Mild soap can be used to clean a superficial burn." D.) "For a superficial burn, I can cover it with a clean nonadherent dressing."
Answer: A.) "I guess my mom was right; she always put ice on our burns when we were kids."
What accurately depicts the hemodynamic changes that occur in the body within the first 24 to 48 hours after a burn? A.) Hematocrit and white blood cell (WBC) counts increase. B.) Hemoglobin and white blood cell (WBC) counts decrease. C.) Hematocrit and white blood cell (WBC) counts decrease. D.) Hematocrit increases and white blood cell (WBC) count decreases.
Answer: A.) Hematocrit and white blood cell (WBC) counts increase.
An infant has presented at the clinic with impetigo. Which organism usually causes impetigo in infants? A.) Staphylococcus aureus B.) Group A beta hemolytic strep C.) Methicillin-resistant Staphylococcus aureus (MRSA) D.) Escherichia coli
Answer: A.) Staphylococcus aureus
The nurse is caring for a 2-year-old boy with a burn. What finding would warrant referral to a burn unit? A.) a chemical burn B.) a superficial or first-degree burn on the hand C.) a superficial or first-degree burn on the chest D.) a superficial or first-degree burn on the upper arm
Answer: A.) a chemical burn
The nurse is taking a health history of a 6-year-old girl with suspected Stevens-Johnson syndrome. During the physical examination, the nurse would expect to note which physical findings? A.) erythema multiforme with inflammatory bullae of at least two types of mucosa B.) fiery red lesions, scaling in the skin folds, and satellite lesions C.) red macules and bullous eruptions on an erythematous base D.) red, raised hair follicles
Answer: A.) erythema multiforme with inflammatory bullae of at least two types of mucosa
The nurse is caring for an infant with diaper dermatitis. Which statement by the child's parent would indicate a need for further education? A.) "I will use a warm blow dryer on the rash area for a few minutes every time I change her diaper." B.) "I will use rubber pants over the cloth diapers in the future." C.) "I can still use fragrance-free diaper wipes." D.) "I can leave her diaper off when she naps each afternoon."
Answer: B.) "I will use rubber pants over the cloth diapers in the future."
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 appointment for the parent to bring the child to the clinic for evaluation. B.) Explain that children who have had a serious injury sometimes exhibit regressive behavior. C.) Tell the parent to allow the child to nurse as much as the child wants. D.) Encourage the parent to explain to the child that he or she must drink from the cup.
Answer: B.) Explain that children who have had a serious injury sometimes exhibit regressive behavior.
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 - flu-like symptoms - headache
Answer: - burning - photosensitivity - dryness
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.) stocking-glove pattern on hands or feet B.) splash patterns C.) nonuniform pattern D.) spattering pattern
Answer: A.) stocking-glove pattern on hands or feet
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? A.) Impaired skin integrity B.) Pain C.) Disturbed body image D.) Risk for fluid volume deficit
Answer: B.) Pain
The nurse is caring for an infant who has impetigo and is hospitalized. Which nursing action is priority? A.) The nurse soaks the skin with warm water. B.) The nurse applies topical antibiotics to the lesions. C.) The nurse follows contact precautions. D.) The nurse applies elbow restraints to the infant.
Answer: C.) The nurse follows contact precautions.
A child has been hospitalized with a diagnosis of severe impetigo. The nurse is interviewing the family. Which question will have the greatest impact on the child's care? A.) "Does your child have any allergies to medications?" B.) "Do you have any concerns about filling the prescriptions?" C.) "How long has the child had the infection?" D.) "Is there anything else you think we should know about your family?"
Answer: A.) "Does your child have any allergies to medications?"
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.) "I will give it to ny child at least 1 hour before all meals." C.) "I will have to watch my child closely for signs of infection." D.) "Since my child has type 1 diabetes, I will need to monitor my child's blood sugar levels closely while on this medication.
Answer: B.) "I will give it to ny child at least 1 hour before all meals." Rationale: 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.
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.) "Does she wear sleepers with metal snaps?" C.) "Do you change her diapers regularly?" D.) "Tell me about your family history of allergies."
Answer: B.) "Does she wear sleepers with metal snaps?"
The nurse is discussing the use of over-the-counter ointments to manage a mild case of diaper rash. What ingredients should the nurse instruct the parents to look for in a compound? Select all that apply. - vitamin A - zinc - vitamin D - vitamin B6 - vitamin B12
Answer: - vitamin A - zinc - vitamin D
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? A.) "Wash your hair with a gentle shampoo daily." B.) "I will let your primary health care provider know you need prescription shampoo." C.) "Wash your hair vigorously twice a day for one week." D.) "Apply warm baby oil to your scalp once a day for a few days."
Answer: A.) "Wash your hair with a gentle shampoo daily."
An adolescent experiencing contact dermatitis reports experiencing pruritis. What intervention will the nurse recommend to relieve the itching? A.) Bathe with a product that is oatmeal-based. B.) Apply calamine lotion if the lesion is weeping. C.) Keep the area covered with clothing. D.) Use a fragrance-free moisturizer.
Answer: A.) Bathe with a product that is oatmeal-based. Rationale: 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.
The nursing diagnosis of risk for infection related to a disruption in the protective skin barrier is noted on a child's plan of care. Which action would be of greatest importance? A.) using appropriate hand hygiene B.) assessing temperature every 4 hours C.) urging adequate nutritional intake D.) obtaining a culture of the impaired skin area
Answer: A.) using appropriate hand hygiene
A 16-year-old male who is diagnosed with tinea pedis questions the nurse about how he may have contracted the condition. How should the nurse respond? A.) "It is unlikely you will be able to determine the cause of the infection." B.) "This condition is common in individuals with lowered immunity." C.) "You may have gotten the condition from a community shower or gym area." D.) "You likely had an infection in another area of your body and it has spread."
Answer: C.) "You may have gotten the condition from a community shower or gym area."
A nurse is working as part of a response team caring for children who have been involved in an elementary school fire. Which children would the nurse identify as needing a referral to a burn unit? Select all that apply. - 8-year-old with an inhalation injury - 6-year-old with burns involving the knees and hips - 10-year-old with second-degree (partial-thickness) burns over 15% of the body - 9-year-old with asthma and burns to the face - 7-year-old with first-degree (superficial) burns over 5% of the body
Answer: - 8-year-old with an inhalation injury - 6-year-old with burns involving the knees and hips - 10-year-old with second-degree (partial-thickness) burns over 15% of the body - 9-year-old with asthma and burns to the face
The nurse is discussing acne vulgaris with a group of adolescents. The teenagers make the following statements regarding the topic. Which statement is the most accurate regarding acne vulgaris? A.) "My mom says I have acne because I eat too much chocolate." B.) "Sometimes I get acne when I use my sister's makeup." C.) "My next door neighbor told me that acne was caused by a fungus." D.) "There is a new immunization that you can get to keep from having acne."
Answer: B.) "Sometimes I get acne when I use my sister's makeup." Rationale: Irritation and irritating substances, such as vigorous scrubbing and cosmetics with a greasy base, can cause acne vulgaris. Increased hormone levels, hereditary factors, and anaerobic bacteria can cause acne vulgaris as well. Eating chocolate and fatty foods does not cause acne, but a well-balanced, nutritious diet does promote healing.
The nurse is caring for a 13-year-old client who asks about acne prevention. Which would be most appropriate for the nurse to suggest? A.) Avoid chocolate and greasy foods. B.) Wash the face with abrasive soaps three times a day. C.) Pop the pimples to make them go away. D.) Wash the face twice a day with a mild soap then pat dry.
Answer: B.) Wash the face with abrasive soaps three times a day.
The nurse is caring for a pediatric client with multiple wounds from a bike accident. What is the best method for cleansing or washing out the wound? A.) Use iodine solution to wash the wound. B.) Use sterile water to wash out the wound. C.) Use normal saline solution to wash the wound. D.) Use an antibiotic wash to cleanse the wound.
Answer: C.) Use normal saline solution to wash the wound.
The nurse has completed client teaching with a 16-year-old female who has been prescribed isotretinoin for cystic acne. Which statements indicate learning has occurred? Select all that apply. - "If I am sexually active I need to let my doctor know." - "As long as I use two forms of birth control I don't need to have monthly pregnancy testing." - "I am young so I won't need to have the liver tests the pamphlet suggests." - "This is not a drug to be used for all forms of acne. My sister has minor acne so I told her this wasn't for her." - "It's important I get my CBC blood test when my doctor orders it."
Answer: - "If I am sexually active I need to let my doctor know." - "This is not a drug to be used for all forms of acne. My sister has minor acne so I told her this wasn't for her." - "It's important I get my CBC blood test when my doctor orders it." Rationale: Accutane (isotretinoin) is a powerful medication used for severe forms of acne and cystic acne when other treatment methods are not effective. Sexual activity should be reported to the physician. Some physicians may order monthly pregnancy tests even if the client says she is not sexually active because of the risk of birth defects to a fetus. No matter what form of birth control is used, pregnancy is possible, so monthly pregnancy tests are still necessary. Liver function tests are important regardless of age because of the side effects of the medication. Any labs ordered by the physician, such as the CBC, to monitor the medication's side effects should be obtained.
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? - Impaired skin integrity - Risk for infection - Disturbed body image - Risk for fluid volume deficit - Knowledge deficit regarding care of wound
Answer: - Impaired skin integrity - Risk for infection
The nurse is conducting a physical examination of a boy with erythema multiforme. Which assessment finding should the nurse expect? A.) lesions over the hands and feet, and extensor surfaces of the extremities with spread to the trunk B.) thick or flaky/greasy yellow scales C.) silvery or yellow-white scale plaques and sharply demarcated borders D.) superficial tan or hypopigmented oval-shaped scaly lesions especially on upper back and chest and proximal arms
Answer: A.) lesions over the hands and feet, and extensor surfaces of the extremities with spread to the trunk
The nurse is caring for a 2-month-old in a pediatric clinic. The mom states she is going on vacation in Florida in a month and she is concerned about sunburn. She asks if it is okay to use a sunscreen lotion made for children. What is the correct nursing response? A.) "It is okay to use a children's sunscreen as long as you avoid the face." B.) "You should not take your infant to Florida." C.) "Put plenty of children's sunscreen on the infant at least 15 minutes before going outdoors, then reapply every three to four hours." D.) "Sunscreen is not recommended until 6 months of age. Use light clothing and a hat to completely cover the child when in the sun."
Answer: D.) "Sunscreen is not recommended until 6 months of age. Use light clothing and a hat to completely cover the child when in the sun."
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? A.) superficial or first-degree B.) partial-thickness or second-degree C.) deep partial-thickness or second-degree D.) full-thickness or third-degree
Answer: D.) full-thickness or third-degree
The nurse is discussing dietary intake with the parents of a 4-year-old child who has been diagnosed with atopic dermatitis. Later, the nurse notes the menu selection made by the parents for the child. Which selection indicates the need for further instruction? A.) peanut butter and jelly sandwich B.) chicken nuggets C.) tomato soup D.) carrot and celery sticks
Answer: A.) peanut butter and jelly sandwich Rationale: Atopic dermatitis is commonly associated with allergies to food. Common culprits may include peanuts, eggs, orange juice, and wheat-containing products.
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? A.) "Baby powder should not be used on newborns due to the risk of aspiration upon application." B.) "Baby powder may be used if sprinkled on your hand away from the baby to prevent aspiration." C.) "Baby powder should not be used since so many people are allergic to the ingredients in it." D.) "Baby powder can be used anytime with no concerns."
Answer: A.) "Baby powder should not be used on newborns due to the risk of aspiration upon application." Rationale: 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.
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? A.) "The sebaceous and sweat glands are fully functional in the infant." B.) "The largest organ of the body helps regulate body temperature." C.) "The integumentary system is not in place until after the child is born and then takes many years to mature." D.) "One role of the integumentary system is to distribute oxygen to the body cells."
Answer: B.) "The largest organ of the body helps regulate body temperature."
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.) Keep follow-up appointments. B.) Perform proper hand hygiene. C.) Complete the prescribed antibiotics. D.) Monitor for signs of worsening condition.
Answer: C.) Complete the prescribed antibiotics. Rationale: 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 admits a 10-year-old who has just eaten lobster and has hives over much of the body. In collecting data regarding this child, which question should the nurse ask the caregiver first? A.) "Has the child ever eaten shellfish before now?" B.) "Is your child allergic to peanuts or other foods?" C.) "Does anyone in your family have any food allergies?" D.) "Have you ever given your child antihistamines?"
Answer: A.) "Has the child ever eaten shellfish before now?" Rationale; The first time the child comes in contact with an allergen, no reaction may be evident, but an immune response is stimulated—helper lymphocytes stimulate B lymphocytes to make the immunoglobulin E (IgE) antibody. The IgE antibody attaches to mast cells and macrophages. When contacted again, the allergen attaches to the IgE receptor sites, and a response occurs in which certain substances, such as histamine, are released; these substances produce the symptoms known as allergy. Asking the other questions is important, but the first question the nurse should ask is related to this child and this situation.
A parent expresses a concern about white scales that have begun to flake off the 1-week-old infant's scalp. The parent asks, "What can I do to prevent this?" Which response by the nurse would be most appropriate? A.) "Your child most likely has infantile seborrheic dermatitis, or cradle cap. You can care for it by cleansing the hair and scalp daily with baby shampoo. You can also apply baby oil to the area for 10 to 15 minutes and then rinse away the flakes." B.) "Your child most likely has dandruff. You can treat it with daily with antiseborrheic shampoo, like Head and Shoulders." C.) "How often do you bathe your infant? The infant should have a thorough shampooing every day to prevent things like this." D.) "Your child most likely has infantile seborrheic dermatitis, or cradle cap. There is no intervention needed and it should resolve in 1 week."
Answer: A.) "Your child most likely has infantile seborrheic dermatitis, or cradle cap. You can care for it by cleansing the hair and scalp daily with baby shampoo. You can also apply baby oil to the area for 10 to 15 minutes and then rinse away the flakes." Rationale: Infantile seborrheic dermatitis usually responds well to cleansing the scalp with a mild shampoo. The thick, scaling lesions on the child's scalp can be treated by applying baby oil, salicylic acid in mineral oil, or a corticosteroid gel on the scalp for 10 to 15 minutes. The area is gently massaged with a soft toothbrush; then the scales can be rinsed away. A fine-toothed comb helps rid the hair of scale debris. Antiseborrheic shampoo is not recommended for infants. Accusing a parent of poor hygiene is inappropriate. Infantile seborrheic dermatitis is not a result of poor hygiene.
An infant is seen in the emergency department with several raised red welts over the abdomen and lower extremities. The parent states that the symptoms developed suddenly over the past few hours. The infant is fussy and has a low grade temperature. What assessment is most important for the nurse to perform? A.) Observe the infant's respiratory effort. B.) Examine the lips and oral mucosa for cyanosis. C.) Question the parent about methods of punishment. D.) Determine whether the child is breastfed or formula fed.
Answer: A.) Observe the infant's respiratory effort. Rationale: The raised red welts are likely urticaria or hives, an allergic response to a substance (food, drugs, plants, etc.). As such, it is most important to observe the infant's respiratory effort since that reaction can involve the lips, tongue, and airway. Cyanosis would not be visible unless the airway was blocked and then it would be central cyanosis, not just circumoral. Questioning the parent about methods of punishment is unnecessary as the welts are not a sign of trauma. It is appropriate to determine if the infant is breastfed or formula fed because it might be related to the hives, especially if the infant was switched from breast milk to formula. This, however, is not the most important assessment.
The nurse is conducting a focused skin assessment on a child. After inspecting the skin and noting drainage, what will the nurse do next? A.) Palpate for regional lymphadenopathy. B.) Obtain a detailed history of prodromal symptoms. C.) Determine if the child has had a temperature elevation. D.) Use the Braden Q scale to determine pressure injury risk.
Answer: A.) Palpate for regional lymphadenopathy. Rationale: To conduct a skin assessment, the nurse begins with a generalized skin survey and notes any distribution of rashes, the types of lesions and the drainage type and amount. Next, the nurse would need to palpate for any regional lymphadenopathy. This is important because lymph nodes drain to specific regions where they are located. If one or more lymph nodes are enlarged, it could be indicative of a systemic infection instead of just a localized skin infection or inflammation. The prodromal symptoms and history of fever would be obtained in the health history and not the skin assessment. The Braden Q scale is a tool to measure risk factors for a pediatric client developing a pressure injury. It could be used in this situation if the child is not eating, is bed bound, etc., but it is not part of the focused assessment process. The findings from the focused assessment would be entered into the tool to calculate risks.
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? A.) "When he plays in the woods again, I will make sure he wears long pants and long sleeves." B.) "As long as he takes a shower as soon as he gets inside, he shouldn't get this again." C.) "I can buy a medicine to put on him before he goes out to prevent him from getting this again." D.) "I will need to make sure the dog gets a bath if he goes in the woods."
Answer: B.) "As long as he takes a shower as soon as he gets inside, he shouldn't get this again." Rationale: 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.
A pediatric client who has been seriously burned is being given IV fluid replacements. It has been determined that the client will initially need 24 ounces of replacement fluids. In following a normal burn replacement treatment for this child, if the treatment is started at 10:00 AM, which of the following would be correct? The child would have received: A.) 12 ounces of IV fluid replacement by 4:00 PM. B.) 12 ounces of IV fluid replacement by 6:00 PM. C.) 18 ounces of IV fluid replacement by 4:00 PM. D.) 18 ounces of IV fluid replacement by 6:00 PM.
Answer: B.) 12 ounces of IV fluid replacement by 6:00 PM. Rationale: Intravenous fluids for maintenance and replacement of lost body fluids are estimated for the first 24 hours, with half of this calculated requirement given during the first 8 hours.
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 with periorbital cellulitis reports changes in vision and pain with eye movement. C.) A child has a red, warm, edematous area over an old spider bite. D.) A child with cellulitis has a temporal temperature of 101°F (38.3°C).
Answer: B.) A child with periorbital cellulitis reports changes in vision and pain with eye movement. Rationale: 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.
A 2-year-old child is brought to the urgent care center for treatment of burns on both hands. The parent reports that the child pulled the coffee pot over and the hot liquid splashed on to the child's hands. The nurse examines the child and notes that the backs of the hands are reddened with a well-defined line of demarcation at the wrists. Several medium to large blisters are also present. What initial action should the nurse take? A.) Contact the authorities to report suspected child abuse (child mistreatment). B.) Make arrangements to transfer the child to the hospital. C.) Determine the depth of the burn injuries. D.) Place ice packs on the hands to stop the burning.
Answer: B.) Make arrangements to transfer the child to the hospital. Rationale: The nurse's initial action to make arrangements for the child to be transferred to the hospital. Burns on the hands or feet of a child are criteria for admission to a burn center. In addition, the nurse should suspect child abuse (child mistreatment) because of the defined lines of demarcation on the burns (glove pattern) which indicates that the child's hands were placed in scalding liquid versus a splash pattern if the pot had been knocked over. Although the nurse may suspect child abuse (child mistreatment), the initial action should be to get the child to the hospital. The depth of the burns can be determined at the hospital. Applying an ice pack could cause additional damage, most notably by breaking the blisters and increasing the risk of infection. Blisters should be left intact. Cool water can be applied to stop the burning and provide some comfort.
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? A.) First-degree or superficial burn B.) Second-degree or partial-thickness burn C.) Third-degree or full-thickness burn D.) Fourth-degree or fat-layer burn
Answer: B.) Second-degree or partial-thickness burn Rationale: 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 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? A.) Pain at a 7 on a 0 to 10 scale B.) Urine output of 15 ml per hour over the last 4 hours C.) Refused dinner due to nausea D.) Weight gain of 0.9 kg over the last 2 days
Answer: B.) Urine output of 15 ml per hour over the last 4 hours Rationale: 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.
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.) community acquired MRSA C.) staphylococcal scalded skin syndrome D.) folliculitis
Answer: B.) community acquired MRSA
An 8-year-old child has had skin testing done for allergies. After a review of the results, it is decided that the child will undergo hyposensitization therapy. The parents are asking the nurse questions about the purpose of this therapy and what to expect. Which information will the nurse include when teaching the parents and child about this therapy? A.) "This therapy works better than trying to avoid the allergens." B.) "Initially the dose will be high and then be gradually decreased." C.) "Your child will have to remain in the office for about one-half hour after each treatment." D.) "The risk for a severe allergic reaction is high, but the benefits are greater."
Answer: C.) "Your child will have to remain in the office for about one-half hour after each treatment."
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.) Use a fragrance-free, dye-free soap to clean the wound. D.) Premedicate the child before changing the dressing.
Answer: D.) Premedicate the child before changing the dressing.
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: A.) seborrheic dermatitis. B.) miliaria rubra (heat rash). C.) candidiasis. D.) impetigo.
Answer: D.) impetigo.