ch 23 nclex
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, 9-year-old with asthma and burns to the face, 10-year-old with partial-thickness burns over 15% of the body
The nurse is caring for a 2-year-old child with a burn. What finding would warrant referral to a burn unit?
A chemical burn
The nurse is caring for a child with a partial-thickness burn. What assessment findings would the nurse expect to observe?
Edema with wet blistering skin
The nurse is taking a health history of a 6-year-old child with suspected Stevens--Johnson syndrome. During the physical examination, the nurse would expect to note which physical findings?
Erythema multiforme with inflammatory bullae of at least two types of mucosa
When assessing an adolescent for acne, what findings would lead the nurse to identify the acne as severe? (Select all that apply.)
Evidence of cysts, Widespread inflammatory lesions, Presence of nodules
The nurse is caring for a 15-year-old adolescent with psoriasis. In addition to the plaques, what would the nurse expect to note?
Fissures and scaling on palms and soles
The nurse is caring for a child with a suspected fungal infection. Which test would the nurse anticipate being ordered?
Potassium hydroxide (KOH) prep
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?
Premedicate the child before changing the dressing.
A 14-year-old child is diagnosed with tinea versicolor. What would the nurse expect the nurse practitioner to order?
Selenium sulfide
The nurse is caring for a 7-year-old child with burns. Which finding would be highly suggestive that the burn is a result of child abuse?
Stocking--glove pattern on hands or feet
A group of nursing students are reviewing information about atopic dermatitis. Which answers indicate that the students understand the information? (Select all that apply.)
The reaction occurs in response to specific allergens., Changes in temperature can contribute to flare-ups., The disorder is chronic with periods of remissions.
The nurse is caring for a child, weighing 100 lb (45.5 kg), on the burn unit who has partial-thickness burns on over 30% of the body. During the beginning shift assessment, which assessment finding is of most concern to the nurse?
Urine output of 15 mL per hour over the last 4 hours
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 priority importance?
Using appropriate hand hygiene
An adolescent is prescribed isotretinoin. Which statement indicates that the adolescent understands the necessary precautions associated with this drug?
"I have to make sure that I do not become pregnant while taking this drug."
The nurse is caring for a 13-year-old adolescent with acne vulgaris and is teaching the adolescent about skin care. Which response by the adolescent indicates a need for further teaching?
"I should avoid eating any kind of chocolate."
The nurse has completed client teaching with a 16-year-old female who has been prescribed isotretinoin for cystic acne. Which client statements indicate learning has occurred? (Select all that apply.)
"It's important I get my CBC blood test when my healthcare provider orders it.", "If I am sexually active I need to let my healthcare provider 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."
The nurse is providing home care instructions for the parents of an infant with cradle cap. Which response by the parents indicates a need for further teaching?
"We can scrape off the crusts on his scalp with a cotton swab."
The nurse is teaching the parents of a 6-year-old child who has sustained a large laceration about providing care to the wound at home. The nurse determines that the parents need additional teaching when they state:
"We need to keep the wound tightly bandaged for at least 3 days."
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?
1 week
The nurse is caring for a child with urticaria. What is the priority action?
Assessing the child's airway and breathing and noting any wheezing or stridor
The nurse is collecting data from a 14-year-old adolescent and parent who have come to the clinic for a check-up. The parent reports that the adolescent has had hives intermittently for the past 2 months. What is the priority action for this client?
Determine the underlying cause.
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.)
Dryness, Burning, Photosensitivity
A nursing instructor is preparing a class discussion about pediatric skin variations, specifically related to differences in dark-skinned children. What information would the nurse most likely include? (Select all that apply.)
Hypopigmentation often occurs after a skin condition heals., Papules often appear more prominent on the skin., Hypertrophic scarring is a common occurrence in dark-skinned children.
A topical corticosteroid is prescribed for a child with contact dermatitis. Which statement by the parent would indicate the teaching was successful?
I should not cover the area with plastic wrap after applying the cream."
The nurse is providing education to an adolescent who has tinea pedis. What information should be included in the discussion? (Select all that apply.)
Keep feet clean and dry., Wear cotton socks.