Integumentary

A child is being seen in the emergency department with multiple facial abrasions and lacerations. Lidocaine, adrenaline, and tetracaine (LAT) is applied topically to the wounds. The purpose of this is: a. to cleanse the wounds. b. to prevent infection. c.to provide anesthesia. d. to promote scab formation.

Ans: C LAT does not have a cleansing effect. LAT has no antibacterial effect. LAT provides anesthesia within 10 to 15 minutes of application. LAT has no effect on scab formation.

After the acute stage and during the healing process, the primary complication from burn injury is: a.Asphyxia. b.Shock. c.Renal shutdown. d.Infection.

ANS: D During the healing phase, local infection and sepsis are the primary complications. Respiratory problems, primarily airway compromise, are the primary complications during the acute stage of burn injury.

The nurse should expect to assess which causative agent in a child who has warts? a. Bacteria b. Fungus c. Parasite d. Virus

ANS: D Human warts are caused by the human papillomavirus. Infection with bacteria, fungus, and parasitic organisms does not result in warts.

Which prescribed treatment should the nurse plan to implement for a child with psoriasis? a.Antihistamines b.Oral antibiotics c.Topical application of calamine lotion d.Tar and exposure to sunlight and ultraviolet light

ANS: D Psoriasis is treated with tar preparations and exposure to ultraviolet B light or natural sunlight. Antihistamines, oral antibiotics, and topical application of calamine lotion are not effective in psoriasis.

Cellulitis is often caused by: a. Herpes zoster. b. Candida albicans. c. Human papillomavirus. d. Streptococcus or Staphylococcus organisms.

ANS: D Streptococcus, Staphylococcus, and Haemophilus influenzae are the organisms usually responsible for cellulitis. Herpes zoster is the virus associated with varicella and shingles. Candida albicans is associated with candidiasis or thrush. Human papillomavirus is associated with various types of human warts.

What is most descriptive of atopic dermatitis (eczema) in the infant? a.Worse in summer b. Worse in humid climates c. Associated with upper respiratory infections d. Associated with hereditary allergies

Ans: D Atopic dermatitis worsens in fall and winter. It improves in humid climates. It is associated with allergies. Most children with atopic dermatitis have a family history of eczema, asthma, food allergies, or allergic rhinitis. This suggests a genetic predisposition.

A nurse should explain that ringworm is: a. not contagious. b. a sign of uncleanliness. c. expected to recover spontaneously. d. spread by direct and indirect contact

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

The only symptom of pediculosis capitis (head lice) is usually: a. Itching. c. Scalp rash. b. Vesicles. d. Localized inflammatory response.

NS: A Itching is generally the only manifestation of pediculosis capitis (head lice). Diagnosis is made by observation of the white eggs (nits) on the hair shaft. Vesicles, scalp rash, and localized inflammatory response are not symptoms of head lice.

A high-protein diet for the child with major burns is ordered to: a.Promote growth. b.Improve appetite. c.Diminish risks of stress-induced hyperglycemia. d.Avoid protein breakdown.

ANS: D The diet must provide sufficient calories to meet the increased metabolic needs and enough protein to avoid protein breakdown. Healing, not growth, is the primary consideration. Many children have poor appetites, and supplementation will be necessary. Hypoglycemia, not hyperglycemia, can occur from the stress of burn injury because the liver glycogen stores are rapidly depleted.

An effective strategy to reduce the stress of burn dressing procedures is to: a.Give the child as many choices as possible. b.Reassure the child that dressing changes are not painful. c.Explain to the child why analgesics cannot be used. d.Encourage the child to master stress with controlled passivity.

ANS: A Children who have an understanding of the procedure and some perceived control demonstrate less maladaptive behavior. They respond well to participating in decisions and should be given as many choices as possible. The dressing-change procedure is very painful and stressful. The child should not be misinformed. Analgesia and sedation can and should be used. Encouraging the child to master stress with controlled passivity is not a positive coping strategy.

Isotretinoin (Accutane) is indicated for the treatment of acne during adolescence when: a.Acne has not responded to other treatments. b.The adolescent is or may become pregnant. c.The adolescent is unable to give up foods causing acne. d.Frequent washing with antibacterial soap has been unsuccessful.

ANS: A Accutane (isotretinoin) is reserved for severe cystic acne that has not responded to other treatments. Accutane has teratogenic effects and should never be used when there is a possibility of pregnancy. No correlation exists between foods and acne. Antibacterial soaps are ineffective. Frequent washing with antibacterial soap is not a recommended therapy for acne.

The management of a child who has just been stung by a bee or wasp should include the application of: a. Cool compresses b. Warm compresses. c. Antibiotic cream. d. Corticosteroid cream.

ANS: A Bee or wasp stings are initially treated by carefully removing the stinger, cleansing with soap and water, applying cool compresses, and using common household agents such as lemon juice or a paste made with aspirin and baking soda. Warm compresses are avoided. Antibiotic cream is unnecessary unless a secondary infection occurs. Corticosteroid cream is not part of the initial therapy. If a severe reaction occurs, systemic corticosteroids may be indicated.

Which nursing intervention is the highest priority in the initial care of a child with a major burn injury? a.Establishing and maintaining the child's airway b.Establishing and maintaining intravenous access c.Insertion of a catheter to monitor hourly urine output d.Insertion of a nasogastric tube into the stomach to supply adequate nutrition

ANS: A Establishing and maintaining the child's airway is always the priority focus for assessment and care. Establishing intravenous access is the second priority in this situation, after the airway has been established. Inserting a catheter and monitoring hourly urine output is the third most important nursing intervention. Nasogastric feedings are not begun initially on a child with major or severe burns. The initial assessment and care focus for a child with major burn injuries is the ABCs.

The nurse is teaching parents of a 3-year-old with impetigo that they can anticipate: a.No scarring. b.Pigmented spots. c.Slightly depressed scars. d.Atrophic white scars.

ANS: A Impetigo tends to heal without scarring unless a secondary infection occurs.

Lymphangitis ("streaking") is frequently seen in: a. Cellulitis. b. Folliculitis. c. Impetigo contagiosa. d. Staphylococcal scalded skin.

ANS: A Lymphangitis is frequently seen in cellulitis. If present, hospitalization is usually required for parenteral antibiotic. Lymphangitis is not associated with folliculitis, impetigo, or staphylococcal scalded skin.

A child with extensive burns requires debridement. The nurse should anticipate that a priority goal related to this procedure is to: a.Reduce pain. b.Prevent bleeding. c.Maintain airway. d.Restore fluid balance

ANS: A Partial-thickness burns require debridement of devitalized tissue to promote healing. The procedure is very painful and requires analgesia and sedation before the procedure. Preventing bleeding, maintaining the airway, and restoring fluid balance are not goals related to debridement.

A child experiences frostbite of the fingers after prolonged exposure to the cold. Which intervention would the nurse implement first? a.Rapid rewarming of the fingers by placing in warm water b.Placing the hand in cool water c.Slow rewarming by wrapping in warm cloth d.Using an ice pack to keep cold until medical intervention is possib

ANS: A Rapid rewarming is accomplished by immersing the part in well-agitated water at 37.8° C to 42.2° C (100° F to 108° F) and results in less tissue necrosis than slow thawing. The frostbitten area should be rewarmed as soon as possible to avoid further tissue damage.

The most immediate threat to life in children with thermal injuries is: a.Shock .b.Anemia. c.Local infection. d.Systemic sepsis.

ANS: A The immediate threat to life in children with thermal injuries is airway compromise and profound shock. Anemia is not of immediate concern. During the healing phase, local infection and sepsis are the primary complications.

Hydrotherapy is required to treat a child with extensive partial-thickness burn wounds. Which is the primary purpose of hydrotherapy? a.Debride the wounds. b.Increase peripheral blood flow. c.Provide pain relief. d.Destroy bacteria on the skin

ANS: A The water acts to loosen and remove sloughing tissue, exudate, and topical medications. Increasing peripheral blood flow, providing pain relief, and destroying bacteria on the skin may be secondary benefits to hydrotherapy, but the primary purpose is for debridement

The nurse is caring for a school-age child with a tinea capitis (ringworm) infection. The nurse should expect that therapeutic management for this child includes: a.Administering oral griseofulvin. b.Administering topical or oral antibiotics. c.Applying topical sulfonamides. d.Applying Burow's solution compresses to affected area.

ANS: A Treatment with the antifungal agent griseofulvin is part of the treatment for the fungal disease ringworm. Oral griseofulvin therapy frequently continues for weeks or months. Antibiotics, sulfonamides, and Burow's solution are not effective in fungal infections.

Which should the nurse include when teaching parents about preventing childhood burn injuries (Select all that apply)? a.Keep hot liquids out of reach. b.Baby-proof electrical outlets. c.Turn water heater thermostats to a maximum of 150° F. d.Heat infant formula in the microwave. e.Test water temperature before placing your child in the tub bath.

ANS: A, B, E To prevent burns, hot liquids should be kept out of reach; tablecloths and dangling appliance cords are often pulled by toddlers, who spill hot grease and liquids on themselves. Electrical cords and outlets represent a potential risk to small children, who may chew on accessible cords and insert objects into outlets. The Consumer Product Safety Commission recommends a reduction of water heater thermostats to a maximum of 48.9° C (120° F). The increased use of microwave ovens has resulted in burn injuries from the extremely hot internal temperatures generated in heated items. Baby formula, jelly-filled pastries, and hot liquids and dishes may result in cutaneous scalds or the ingestion of overheated liquids. Water should always be tested before a child is placed in the tub or shower.

Where do the lesions of atopic dermatitis most commonly occur in the infant (Select all that apply)? a.Cheeks b.Buttocks c.Extensor surfaces of arms and legs d.Back e.Trunk f.Scalp

ANS: A, C, E, F The lesions of atopic dermatitis are generalized in the infant. They are most commonly on the cheeks, scalp, trunk, and extensor surfaces of the extremities. Lesions do not generally occur on the buttocks and the back.

The community health nurse is teaching parents about prevention of the spread and reoccurrence of pediculosis (head lice). Which should the nurse include in the teaching session (Select all that apply)? a.Dry-clean nonwashable items. b.Spray the environment with an insecticide. c.Seal nonwashable items in a plastic bag for 5 days. d.Boil combs and brushes for 10 minutes. e.Discourage sharing of personal items.

ANS: A, D, E To prevent the spread and reoccurrence of pediculosis, the nurse should teach the parents to dry-clean nonwashable items; boil combs and brushes for 10 minutes or soak for 1 hour in a pediculicide; and discourage the sharing of personal items, such as combs, hats, scarves and other headgear. Spraying with insecticide is not recommended because of the danger to children and animals. Nonwashable items should be sealed for 14 days in a plastic bag.

The nurse is examining 12-month-old Amy, who was brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with satellite lesions that cross the inguinal folds. This is most likely caused by: a.Impetigo .b.Candida albicans. c.Urine and feces. d.Infrequent diapering.

ANS: B Candida albicans infection produces perianal inflammation and a maculopapular rash with satellite lesions that may cross the inguinal folds. Impetigo is a bacterial infection that spreads peripherally in sharply marginated irregular outlines. Eruptions involving the skin in contact with the diaper but sparing the folds are likely to be caused by chemical irritation, especially urine and feces.

The nurse is teaching a class on preventing diaper rash in newborns to a group of new parents. Which statement made by a parent indicates a correct understanding of the teaching? a."I should wash my infant's buttocks with soap and water every time I change the diaper." b."I will wash with a mild soap and water and dry thoroughly whenever my infant has a bowel movement." c."I should wash my infant's buttocks with soap before applying a thin layer of oil." d. "I will apply baby oil and powder to the creases in my infant's buttocks."

ANS: B Change the diaper as soon as it becomes soiled. Gently wipe stool from skin with water and mild soap. Overwashing the skin should be avoided, especially with perfumed soaps or commercial wipes, which may be irritating. The skin should be thoroughly dried after washing. Application of oil does not create an effective barrier. Baby powder should not be used because of the danger of aspiration.

A child is admitted with extensive burns. The nurse notes that there are burns on the child's lips and singed nasal hairs. The nurse should suspect that the child has: a.A chemical burn. b.An inhalation injury. c.An electrical burn. d.A hot-water scald.

ANS: B Evidence of an inhalation injury is burns of the face and lips, singed nasal hairs, and laryngeal edema. Clinical manifestation may be delayed for up to 24 hours. Chemical and electrical burns and those associated with hot-water scalds would not have singed nasal hair.

An important consideration for the nurse when changing dressings and applying topical medication to a child's abdomen and leg burns is to: a.Apply topical medication with clean hands. b.Wash hands and forearms before and after dressing change. c.If dressings adhere to the wound, soak in hot water before removal. d.Apply dressing so that movement is limited during the healing process.

ANS: B Frequent hand and forearm washing is the single most important element of the infection control program. Topical medications should be applied with a tongue blade or gloved hand. Dressings that have adhered to the wound can be removed with tepid water or normal saline. Dressings are applied with sufficient tension to remain in place but not too tight to impair circulation or limit motion.

A toddler sustains a minor burn on the hand from hot coffee. The first action in treating this burn is to: a.Apply ice to burned area. b.Hold the burned area under cool running water. c.Break any blisters with a sterile needle. d.Clean the wound with soap and warm water.

ANS: B In minor burns, the best method to stop the burning process is to hold the burned area under cool running water. Ice is not recommended. Removal of blisters is not generally accepted therapy unless the injury is from a chemical substance. Cooling is necessary to stop the burning process, so the wound should not be cleaned with warm water.

The primary clinical manifestation of scabies is: a. Edema. b. Redness. c. Pruritus. d.Maceration.

ANS: C Scabies is caused by the scabies mite. The inflammatory response and intense itching occur after the host has become sensitized to the mite. This occurs approximately 30 to 60 days after initial contact. In the previously sensitized person the response occurs within 48 hours. Edema, redness, and maceration are not observed in scabies.

Ringworm, frequently found in schoolchildren, is caused by: a. Virus .b.Fungus. c. Allergic reaction. d. Bacterial infection.

ANS: B Ringworm is caused by a group of closely related filamentous fungi that invade primarily the stratum corneum, hair, and nails. They are superficial infections that live on, not in, the skin. Virus and bacterial infection are not causative organisms for ringworm. Ringworm is not an allergic response.

Rocky Mountain spotted fever is caused by the bite of a: a.Flea. c.Mosquito. b.Tick. d.Mouse or rat.

ANS: B Rocky Mountain spotted fever is caused by a tick. The tick must attach and feed for at least 1 to 2 hours to transmit the disease. The usual habitat of the tick is in heavily wooded areas. Fleas, mosquitoes, mice, and rats do not transmit Rocky Mountain spotted fever.

Which primary treatment will the nurse implement for a child with warts? a.Vaccination b.Local destruction c.Corticosteroids d.Specific antibiotic therapy

ANS: B Topical treatments include chemical cautery, which is especially useful for the treatment of warts. Local destructive therapy is individualized according to location, type, and number. Surgical removal, electrocautery, curettage, cryotherapy, caustic solutions, x-ray treatment, and laser therapies are used. Vaccination is prophylaxis for warts and is not a treatment. Corticosteroids and specific antibiotic therapy are not effective in the treatment of warts.

Biologic dressings are applied to a child with partial-thickness burns of both legs. Nursing actions related to this include: a.Observing wounds for bleeding. b.Observing wounds for signs of infection. c.Monitoring closely for signs of shock. d.Splinting legs to prevent movement.

ANS: B When applied early to a superficial partial-thickness injury, biologic dressings stimulate epithelial growth and faster wound healing. If the dressing covers areas of heavy microbial contamination, infection occurs beneath the dressing. In the case of partial-thickness burns, such infection may convert the wound to a full-thickness injury. Observing wounds for bleeding, monitoring for shock, and splinting legs are important, but infection is the primary concern when biologic dressings are used.

Which statement regarding atopic dermatitis (eczema) in the infant is most accurate? a.It is easily cured. b.It is worse in humid climates. c.It is associated with upper respiratory tract infections. d.It is associated with allergy with a hereditary tendency.

ANS: D Atopic dermatitis is a type of pruritic eczema that usually begins during infancy and is associated with allergy with a hereditary tendency. It can be controlled but not cured. Manifestations of the disease are worse when environmental humidity is lower. Atopic dermatitis is not associated with respiratory infections.

The nurse is speaking with the parent of an infant with severe atopic dermatitis. What information should the nurse reinforce with the parent (Select all that apply)? a."You can use warm wet compresses to relieve discomfort." b."You will need to keep your infant's skin well hydrated by using a mild soap in the bath." c."You should bathe your baby in a bubble bath two times a day." d."You will need to prevent your baby from scratching the area by using a mild antihistamine." e."You can try a fabric softener in the laundry to avoid rough cloth." f."You should apply an emollient to the skin immediately after a bath."

ANS: B, D, F The eczematous lesions of atopic dermatitis are intensely pruritic. Scratching can lead to new lesions and secondary infection; an antihistamine can be used. Keeping the skin hydrated is a goal of treating atopic dermatitis. Applying an emollient immediately after a bath helps to trap moisture and prevent moisture loss. Using warm compresses to relieve discomfort, bathing the baby in a bubble bath, and using fabric softener are not appropriate suggestions for this condition.

An important nursing consideration when caring for a child with impetigo contagiosa is to: a. Apply topical corticosteroids to decrease inflammation. b. Carefully remove dressings so as not to dislodge undermined skin, crusts, and debris. c. Carefully wash hands and maintain cleanliness when caring for an infected child. d. Examine child under a Wood's lamp for possible spread of lesions.

ANS: C A major nursing consideration related to bacterial skin infections such as impetigo contagiosa is to prevent the spread of the infection and complications. This is done by thorough hand washing before and after contact with the affected child. Corticosteroids are not indicated in bacterial infections. Dressings are usually not indicated. The undermined skin, crusts, and debris are carefully removed after softening with moist compresses. A Wood's lamp is used to detect fluorescent materials in the skin and hair. It is used in certain disease states such as tinea capitis.

father calls the clinic nurse because his 2-year-old child was bitten by a black widow spider. The nurse should advise the father to: a.Apply warm compresses. b.Carefully scrape off the stinger. c.Take the child to emergency department. d.Apply a thin layer of corticosteroid cream.

ANS: C The brown recluse spider has venom that is toxic enough to be harmful. The father should take the child to the emergency department for immediate treatment. Warm compresses increase the circulation to the area and facilitate the spread of the venom. The black widow spider does not have a stinger. Corticosteroid cream has no effect on venom.

Which of the following best describes a full-thickness (third-degree) burn? a.Erythema and pain b.Skin showing erythema followed by blister formation c.Destruction of all layers of skin evident with extension into subcutaneous tissue d.Destruction injury involving underlying structures such as muscle, fascia, and bone

ANS: C A third-degree or full-thickness burn is a serious injury that involves the entire epidermis and dermis and extends into the subcutaneous tissues. Erythema and pain are characteristic of a first-degree or superficial burn. Erythema with blister formation is characteristic of a second-degree or partial-thickness burn. A fourth-degree burn is a full-thickness burn that also involves underlying structures such as muscle, fascia, and bone.

One of the first signs of overwhelming sepsis in a child with burn injuries is: a.Seizures. b.Bradycardia. c.Disorientation. d.Decreased blood pressure

ANS: C Disorientation in the burn patient is one of the first signs of overwhelming sepsis and may indicate inadequate hydration. Seizures, bradycardia, and decreased blood pressure are not initial manifestations of overwhelming sepsis.

Fentanyl and midazolam (Versed) are given before debridement of a child's burn wounds. These drugs are important to: a.Promote healing. b.Prevent infection. c.Provide pain relief. d.Limit amount of debridement that will be necessary.

ANS: C Fentanyl and midazolam provide excellent intravenous sedation and analgesia to control procedural pain in children with burns.

The nurse should understand that Lyme disease is: a.Difficult to prevent. b.Easily treated with oral antibiotics in stages 1, 2, and 3. c.Caused by a spirochete that enters the skin through a tick bite. d.Common in geographic areas where the soil contains the mycotic spores that cause the disease.

ANS: C Lyme disease is caused by Borrelia burgdorferi, a spirochete spread by ticks. The early characteristic rash is erythema migrans. Tick bites should be avoided by entering tick-infested areas with caution. Light-colored clothing should be worn to identify ticks easily. Long-sleeve shirts and long pants tucked into socks should be the attire. Early treatment of the erythema migrans (stage 1) can prevent the development of Lyme disease. It is caused by a spirochete, not mycotic spore.

The nurse is caring for a 7-year-old with herpes simplex virus. Which prescribed medication should the nurse expect to be included in the treatment plan? a.Corticosteroids b.Oral griseofulvin c.Oral antiviral agent d.Topical and/or systemic antibiotic

ANS: C Oral antiviral agents are effective for viral infections such as herpes simplex. Corticosteroids and antibiotics are not effective for viral infections. Griseofulvin is an antifungal agent and not effective for viral infections.

A child steps on a nail and sustains a puncture wound of the foot. The most appropriate method for cleansing this wound is to: a. Wash wound thoroughly with chlorhexidine. b. Wash wound thoroughly with povidone-iodine. c. Soak foot in warm water and soap. d. Soak foot in solution of 50% hydrogen peroxide and 50% water.

ANS: C Puncture wounds should be cleansed by soaking the foot in warm water and soap. Chlorhexidine, hydrogen peroxide, and povidone-iodine should not be used because they have a cytotoxic effect on healthy cells and minimal effect on controlling infection.

Nursing care of the infant with atopic dermatitis focuses on: a.Feeding a variety of foods. b.Keeping lesions dry. c.Preventing infection. d.Using fabric softener to avoid rough cloth.

ANS: C The eczematous lesions of atopic dermatitis are intensely pruritic. Scratching can lead to new lesions and secondary infection. The infant's nails should be kept short and clean and have no sharp edges. During periods of irritability, these children tend to have a decreased appetite. The restriction of hyperallergenic foods, such as milk, dairy products, peanuts, and eggs, may make adequate nutrition a challenge with these children. Wet soaks and compresses are used to keep the lesions moist and minimize the pruritus. Fabric softener should be avoided because of the irritant effects of some of its components.

Herpes zoster is caused by the varicella virus and has an affinity for: a. Sympathetic nerve fibers. b. Parasympathetic nerve fibers. c. Posterior root ganglia and the posterior horn of the spinal cord. d. Lateral and dorsal columns of the spinal cord.

ANS: C The herpes zoster virus has affinity for posterior root ganglia, the posterior horn of the spinal cord, and skin, and does not involve sympathetic or parasympathetic nerve fibers, or lateral and dorsal columns of the spinal cord.

Tretinoin (Retin-A) is a topical agent commonly used to treat acne. Nursing considerations with this drug include: a.Avoiding use of sunscreen agents. b.Using cosmetics with lanolin and petrolatum. c.Explaining that medication should not be applied until at least 20 to 30 minutes after washing. d.Explaining that erythema and peeling are indications of toxicity.

ANS: C The medication should not be applied for at least 20 to 30 minutes after washing to decrease the burning sensation. Avoiding sun and using sunscreen agents must be emphasized because sun exposure can result in severe sunburn. Cosmetics with lanolin, petrolatum, vegetable oil, lauryl alcohol, butyl stearate, and oleic acid can increase comedone production. Erythema and peeling are common local manifestations.

To best assess the child with severe burns for adequate perfusion, the nurse monitors: a.Distal pulses .b.Skin turgor. c.Urine output. d.Mucous membranes.

ANS: C Urine output reflects the adequacy of end-organ perfusion. Distal pulses may be affected by many variables. Urine output is the most reliable indicator of end-organ perfusion. Skin turgor is often difficult to assess on burn patients because the skin is not intact. Mucous membranes do not reflect end-organ perfusion.

A mother calls the emergency department nurse because her child was stung by a scorpion. The nurse should recommend: a.Administering antihistamine. b.Cleansing with soap and water. c.Keeping the child quiet and coming to emergency department. d.Removing the stinger and applying cool compresses.

ANS: C Venomous species of scorpions inject venom that contains hemolysins, endotheliolysins, and neurotoxins. The absorption of the venom is delayed by keeping the child quiet and the involved area in dependent position. Antihistamines are not effective against scorpion venom. The wound will have intense local pain. Cleansing the wound, removing the stinger, and applying cool compresses are not effective. Emergency treatment is indicated.

Which physiologic change causes the edema formation that occurs with burns? a.Vasoconstriction b.Decreased capillary permeability c.Increased capillary permeability d.Decreased hydrostatic pressure within capillaries

ANS: C With a major burn, an increase in capillary permeability occurs, allowing plasma proteins, fluids, and electrolytes to be lost. Maximal edema in a small wound occurs about 8 to 12 hours after injury. In larger injuries, the maximal edema may not occur until 18 to 24 hours after injury. Vasoconstriction, decreased capillary permeability, and decreased hydrostatic pressure within capillaries are not physiologic mechanisms for edema formation in burn patients.

An adolescent girl is cooking on a gas stove when her bathrobe catches fire. Her father smothers the flames with a rug and calls an ambulance. She has sustained major burns over much of her body. What is important in her immediate care? a.Wrap her in a blanket until help arrives b.Encourage her to drink clear liquids c.Place her in a tub of cool water d.Remove her burned clothing and jewelry

ANS: D In major burns, burned clothing should be removed to avoid further damage from smoldering fabric and hot beads of melted synthetic materials. Jewelry is also removed to eliminate the transfer of heat from the metal and constriction resulting from edema formation. The burns should be covered, not wrapped, with a clean cloth. A blanket can be used initially to stop the burning process. Fluids should not be given by mouth to avoid aspiration and water intoxication. The child should be kept warm. Placing her in a tub of cool water will further exacerbate heat loss.

A child falls on the playground and has a small laceration on the forearm. What should the school nurse do to cleanse the wound? a. Slowly pour hydrogen peroxide over wound. b. Soak arm in warm water and soap for at least 30 minutes. c. Gently cleanse with sterile pad and a nonstinging povidone-iodine solution. d. Wash wound gently with mild soap and water for several minutes.

ANS: D Lacerations should be washed gently with mild soap and water or normal saline. A sterile pad is not necessary, and hydrogen peroxide and povidone-iodine should not be used because they have a cytotoxic effect on healthy cells and minimal effect on controlling infection. Soaking the arm does not effectively clean the wound.

The nurse is teaching parents of toddlers about animal safety. Which information should be included in the teaching session? a.Petting dogs in the neighborhood should be encouraged to prevent fear of dogs. b.The toddler is safe to approach an animal if the animal is chained. c.It is permissible for your toddler to feed treats to a dog. d.Teach your toddler not to disturb an animal that is eating.

ANS: D Parents should be taught that toddlers should not disturb an animal that is eating, sleeping, or caring for young puppies or kittens. The child should avoid all strange animals and not be encouraged to pet dogs in the neighborhood. The child should never approach a strange dog that is confined or restrained. The inexperienced child should not feed a dog (if the child pulls back when the animal moves to take the food, this can frighten and startle the animal).

Matt's mother tells the nurse that he keeps scratching the areas where he has poison ivy. The nurse's response should be based on knowing that: a. Poison ivy does not itch and needs further investigation. b. Scratching the lesions will not cause a problem. c. Scratching the lesions will cause the poison ivy to spread. d. Scratching the lesions may cause them to become secondarily infected.

ANS: D Poison ivy is a contact dermatitis that results from exposure to the oil urushiol in the plant. Every effort is made to prevent the child from scratching because the lesions can become secondarily infected. The poison ivy produces localized, streaked or spotty, oozing, and painful impetiginous lesions. Itching is a common response. The lesions do not spread by contact with the blister serum or by scratching.

The family of a 4-month-old infant will be vacationing at the beach. The best recommendation to this family is to: a.Use sun block on the infant's nose and ear tips. b.Use a topical sunscreen product with a sun protective factor of 15. c.Expose the infant to the sun for 15-minute increments. d.Keep the infant in total shade at all times.

ANS: D The infant should be kept out of the sun or physically shaded from it. Fabric with a tight weave, such as cotton, offers good protection. Infants should be covered with clothing or kept in the shade to prevent sun damage to the delicate skin at all times. The blocker can protect the nose and ear tips, but none of the infant's skin should be exposed even for short time periods. Sunscreens should not be used extensively on infants younger than 6 months.

The nurse is talking to the parents of a child with pediculosis capitis. Which should the nurse include when explaining how to manage pediculosis capitis? a."You will need to cut the hair shorter if infestation and nits are severe." b."You can distinguish viable from nonviable nits, and remove all viable ones." c."You can wash all nits out of hair with a regular shampoo." d."You will need to remove nits with an extra-fine tooth comb or tweezers."

ANS: D Treatment consists of the application of pediculicide and manual removal of nit cases. An extra-fine tooth comb facilitates manual removal. Parents should be cautioned against cutting the child's hair short; lice infest short hair as well as long. It increases the child's distress and serves as a continual reminder to peers, who are prone to tease children with a different appearance. It is not possible to differentiate between viable and nonviable eggs. Regular shampoo is not effective; a pediculicide is necessary.

A nurse is caring for a client who has a major burn and is experiencing severe pain. Which of the following actions should the nurse implement to manage this client's pain? A. Administer morphine sulfate IV via continuous infusion B. Administer meperidine IM as needed C. Administer acetaminophen P.O. every 4 hr. D. Administer hydrocodone P.O. every 6 hr.

Ans: A

A nurse is caring for an adolescent who has acne and a prescription for isotretinoin from the dermatologist. Which of the following lab findings should the nurse plan to monitor? A. Cholesterol and triglycerides B. BUN and creatinine C. Serum potassium D. Serum sodium

Ans: A

A nurse is teaching the parent of an infant who has seborrheic dermatitis of the scalp. Which of the following instructions should the nurse include in the teaching? A. "You can use petrolatum to help soften and remove patches from your infants scalp." B. "When patches are present you should keep your infant away from others" C. "You should avoid washing your infants hair while patches are present on scalp." D. "When the patches are present it indicates that your infant has a systemic infection."

Ans: A

The nurse is caring for a 12-year-old boy who sustained major burns when he put charcoal lighter on a campfire. The nurse observes that he is "very brave" and appears to accept pain with little or no response. The most appropriate nursing action related to this is to: a.request a psychologic consultation. b. ask the child why he does not have pain. c.praise the child for his ability to withstand pain. d.encourage continued bravery as a coping strategy.

Ans: A A psychologic consultation will assist the child to verbalize fears. This age group is concerned with physical appearance. The psychologists can help integrate the issues that the child is facing. It is likely that the child is having pain but not acknowledging it. If the child is feeling pain, the nurse should not praise him for hiding it. This may not be an effective coping strategy if the child is in severe pain.

A nurse is caring for a child who has contact dermatitis due to poison ivy. Which of the following actions should the nurse take? (Select all that apply) A. Remove the clothing over the rash. B. Initiate contact isolation precautions while the rash is present C. Expose the rash to a heat lamp for 15 min. D. Cleanse the affected skin with hydrogen peroxide solution E. Apply calamine lotion to the skin

Ans: A, E

A mother of a 12-year-old child informs the phone triage nurse that she has just removed a tick from her daughter's scalp and asks whether she needs to be concerned about Rocky Mountain spotted fever. The nurse's BEST response includes teaching about the clinical manifestations to look out for which include: (Select all that apply.) a.fatigue. b.fever. c. petechial rash. d.severe headache. e. severe diarrhea.

Ans: A,B,C,D Clinical manifestations of Rocky Mountain spotted fever are: Gradual onset—Fever, malaise, anorexia, myalgia Abrupt onset—Rapid temperature elevation, chills, vomiting, myalgia, severe headache Maculopapular or petechial rash primarily on extremities (ankles and wrists) but may spread to other areas, characteristically on palms and soles Abrupt onset of chills, fever, diffuse myalgia, headache, malaise Maculopapular rash becoming petechial 4 to 7 days later, spreading from trunk outward Headache, arthralgia, backache followed by fever; may last 9 to 14 days Maculopapular rash after 1 to 8 days of fever; begins in trunk and spreads to periphery; rarely involves face, palms, soles

A nurse is assessing an infant who has eczema. Which of the following findings should the nurse expect? (Select all that apply) A. Generalized distribution of lesions B. Papules C. Ecchymosis in flexural areas D. Crusting lesions E. Keratosis pilaris

Ans: A,B,D

A nurse is caring for a client who has major burns and suspected septic shock. Which of the following findings are consistent with septic shock? (Select all that apply) A. Increases body temperature B. Altered sensorium C. Decreased capillary refill D. Decreased urine output E. Increased bowel sounds

Ans: A,B,D,

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

Ans: A,C,E 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. Prolonged infection affects the healing process and causes increased scarring

A nurse is caring for a client who has a superficial partial-thickness burn. Which of the following actions should the nurse take? A. Administer IV infusion of 0.9% sodium chloride B. Apply cool, wet compresses to the affected area C. Clean the affected area using a soft-bristled brush D. Administer morphine sulfate

Ans: B

When teaching the adolescent about the management of acne, what intervention should the nurse include? 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 and then cleanse with alcohol.

Ans: B Antibacterial soaps may be too drying when used in combination with topical medications. Cleansing the face with mild soap and water will remove surface dirt and oil. No relationship has been established between food intake and acne. This 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 him or her 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.

Ans: B Only the affected child needs to be treated. The mite responsible for the 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. A scabicide is used. Permethrin and lindane are currently used for topical administration. Permethrin is applied to all skin surfaces.

During the rehabilitative phase of care, pressure dressings are primarily applied to burned areas to: a.relieve pain. b.decrease the blood supply to the scar. c.limit motion during the healing process. d.encourage healing through scar formation.

Ans: B The goal of the pressure dressing is to improve the appearance of scars. Uniform pressure to the scar decreases 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. C. Motion is encouraged; it prevents contractures. 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.

Ans: B These should not be used because they are toxic to the wound. Normal saline is the only acceptable fluid for irrigation listed. The nurse should cleanse the wound with a forced stream of normal saline or water. These should not be used because they are toxic to the wound. These should not be used because they are toxic to the wound.

What is the most important step in the management of cellulitis? a. Burow's solution compresses b. Oral or parenteral antibiotics c. Topical application of an antibiotic d. Incision and drainage of severe lesions

Ans: B Warm water compresses may be indicated for limited cellulitis. Oral or parenteral antibiotics are indicated, depending on the extent of the cellulites. The antibiotic needs to be administered systemically. If done, there is a risk of spreading infection or making the lesion worse.

A nurse is planning care for an infant who has diaper dermatitis. Which of the following actions should the nurse include in the plan of care? (Select all that apply) A. Apply talcum powder with every diaper change B. Allow the buttocks to air dry C. Use commercial baby wipes to cleanse the area D. Use cloth diapers until the rash is gone E. Apply zinc oxide ointment to the affected area

Ans: B, E

A nurse is caring for a client who has a skin graft. Which of the following manifestations indicate infection? (Select all that apply)

Ans: B,D,E

Enteral feedings are ordered for a young child with burns covering 40% of 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 the use of enteral feedings. d. the feedings will be high carbohydrate, low protein.

Ans: C Oral feedings are not contraindicated. They are encouraged; however, most children with burns are unable to consume sufficient calories by mouth. Enteral feedings can continue during procedures. Enteral feedings can begin when the paralytic ileus resolves. A high-protein, high-calorie diet is recommended.

An occlusive dressing, Acu-derm, 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 the wound. c. maintain a moist environment for healing. d.promote mechanical friction for healing.

Ans: C The dressing does not have antiseptic capabilities. The dressing does not have vitamin C. Occlusive dressings such as Acu-derm provide a dressing that does not adhere to the wound site. It provides a moist wound surface and insulates the wound. It protects against friction.

The school nurse is seeing a child who brought poison ivy to school in his leaf collection. He says that only his hands touched it. The most appropriate nursing action is to: a. apply Burow's solution compresses. b. soak his hands in warm water. c. rinse his hands in cold, running water. d. scrub his hands thoroughly with antibacterial soap.

Ans: C This is effective for soothing the skin lesions, once the dermatitis has begun. Cold, running water is effective in removing the oil. This 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. The antibacterial soap removes protective skin oils and dilutes the urushiol, allowing it to spread.

When applying wet compresses or dressings to the skin, the nurse should: a. apply the dressing so the area is totally immobilized. b. apply the dressing when it is saturated and dripping. c. pour or syringe new solution over a dressing that has become dry. d. apply the desired solution on cotton gauze or soft cotton cloths such as clean handkerchiefs.

Ans: D The moist dressing should be laid flat on the area with an attempt to avoid restriction of movement. After immersion in the solution, the dressings are wrung out to avoid dripping. As the evaporation begins to dry them, the dressings are removed, rewet in the solution, and reapplied using aseptic technique. 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. The desired solution should be applied to Kerlix gauze; soft cotton cloths; or strips from cloth diapers, sheets, handkerchiefs, or pillowcase material.

A nurse is teaching a parent of a child who has pediculosis capitis. Which of the following actions should the nurse include in the plan of care? (Select all that apply) A. Treat infected house pets B. Use selenium sulfide shampoo C. Cleanse area with burrow solutions D. Administer antiviral medications E. Use moist, warm compresses

Ans: a, b

A nurse is assessing an infant who has scabies. Which of the findings should the nurse expect? (Select all that apply) A. Presence of nits on the hair shaft B. Pencil-like marks on hands C. Blisters on the soles of the feet D. Small red bumps on the scalp E. Pimples on the trunk

Ans: b, c, e

A nurse teaching a group of parents about preventing insect bites. Which of the following information should the nurse include in the teaching? (Select all that apply) A. Wear perfumes when outside B. Avoid areas of tall grass C. Wear bright-colored clothing D. Wear insect repellent E. Check house pets frequently

Ans: b, d, e

A nurse is caring for a child who has cellulitis on the hand. Which of the following actions should the nurse take? A. Administer oral antibiotics B. Cleanse area using burrow solution C. Prepare for cryotherapy D. Apply topical anti fungal medication

Ans: c

A nurse is caring for a client who has a moderate burn. Which of the following actions should the nurse take? A. Maintain immobilization of the affected area B. Expose affected area to the air C. Initiate a high-protein high-calorie diet D. Implement contact isolation

Ans:C