Chapter 30: Caring for the Child With a Integumentary Condition Nursing School Test Banks

Chapter 30: Caring for the Child With a Integumentary Condition

MULTIPLE CHOICE

1. A motherbaby nurse is demonstrating swaddling a neonate as a method of keeping the baby warm. The mother asks why she needs to be so careful about the babys temperature. Which response by the nurse is the most appropriate?
A. After being in your womb for 9 months, this is how the baby prefers to stay.
B. Babies immune systems are immature; any cold breeze will make them sick.
C. Their skin is thin and they have little fat, so its hard to control their temperature.
D. You need to keep their temperature above what we call normal to keep them well.
ANS: C
Babies have thin skin, a large body surface area, scanty subcutaneous fat, and immature neurological systems. All these factors combined make it difficult for a baby to regulate his or her temperature. The other statements are not factual or informative.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

2. A nurse is working with a child who has a chronic skin disorder consisting of many vesicles and pustules. Which nursing assessment indicates that a priority long-term goal has been met?
A. Child states that he no longer gets teased at school because of his appearance.
B. Parents and child verbalize acceptance of disease process and need for medication.
C. Patient participates in sporting events and other after school-activities regularly.
D. Skin around primary lesions remains free of redness, warmth, swelling, and pain.
ANS: D
All options show evidence of positive outcomes. However, physical needs take priority over psychosocial needs, so absence of infection is evidence that a priority goal has been met. Secondary infection can occur due to scratching, picking, and the presence of the lesions themselves.

Cognitive Level: Evaluation/Evaluating
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Evaluation
Difficulty: Moderate

PTS: 1

3. A child takes anti-inflammatory medications for a chronic condition. The mother asks the nurse why the childs cuts and scrapes seem to take so long to heal. Which response by the nurse is the most appropriate?
A. Chronic diseases always affect the healing process.
B. Inflammation is the first stage of healing wounds.
C. Sick kids tend to be anemic, which often delays healing.
D. Wound healing would not be affected in your child.
ANS: B
The first stage of healing consists of the inflammatory process, which is being hampered by this childs need to take chronic anti-inflammatory medications. Although chronic disease can affect healing, this answer is too vague to be useful. Not all sick children are anemic. Wound healing definitely would be affected in this child.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

4. An adolescent patient has acne characterized by pustules and scarring. Which teaching information is most appropriate for the nurse to give the patient and family?
A. Scrub your face vigorously twice a day with soap and water.
B. Tetracycline (Sumacin) will make you more sensitive to the sun.
C. Use good moisturizer because treatment is very drying.
D. You need a pregnancy test every 3 months on isotretinoin (Accutane).
ANS: B
Tetracycline, minocyline, and doxycycline all cause photosensitivity, so the nurse should warn the teen about sun exposure and use of tanning beds. Skin cleansing should be gentle. Although acne treatments are very drying, makeup and moisturizers should not be applied on top of the dry skin. Pregnancy tests are done prior to starting treatment with Accutane, every month during treatment, and 1 month after treatment has stopped.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

5. A toddler has a few vesicular lesions on his hands that rupture, producing a honey-colored, sticky exudate. Based on this assessment, which medication does the nurse teach the parents about?
A. Azithromycin (Zithromax)
B. Amoxicillin/clavulanate (Augmentin)
C. Doxycycline (Vibramycin)
D. Mupirocin (Bactroban) ointment
ANS: D
This child has impetigo, which is treated in one of two ways. For limited lesions (which this child has), topical Bactroban is appropriate. For widespread lesions, Augmentin is one of the antibiotics used. Azithromycin and doxycycline are not used.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

6. An adolescent is in the clinic with a few skin lesions on his thighs. The lesions have an open center with a thin crust. Which question by the nurse will aid the diagnosis of this patients skin problem?
A. Are you active in any athletics or sports?
B. Do you have siblings with respiratory infections?
C. Do you seem to scratch a lot at night?
D. Have you been in any wooded areas lately?
ANS: A
This lesion sounds like MRSA (methicillin-resistant Staphylococcus aureus). MRSA is common in athletes. This question would elicit the most useful information. Respiratory infection is not related. Scratching, especially at night, is characteristic of scabies. Wooded areas have ticks, which can spread Lyme disease.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

7. A child in the emergency department has cellulitis on the forearm. A nursing student is preparing to administer benzathine penicillin (Bicillin LA). Which action by the nursing student warrants intervention by the staff nurse?
A. Instructs the family members that they must wait at least 15 minutes before leaving
B. Plans to use a 25-gauge, -inch needle to administer the medication
C. Reconstitutes the medication using sterile normal saline solution
D. Selects a large, well-defined muscle for a deep intramuscular injection
ANS: B
Bicillin LA is given by a deep intramuscular injection. This needle is used for subcutaneous injections. The other options are all correct actions the student should take.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

8. The pediatric clinic nurse assesses small, pink pearl-like lesions on the trunk of a school-aged child. Which treatment regimen does the nurse plan to teach the family about based on the assessment findings?
A. Antibiotics twice a day for 710 days
B. Cleaning the bathtub after the child bathes
C. Intramuscular injection of an antibiotic
D. Topical use of tretinoin (RetinA) on lesions
ANS: B
This child has manifestations of molluscum contagiosum, a viral infection that generally resolves on its own. Because this is contagious, the bathtub should be disinfected after the child bathes and his or her towels should not be shared. More aggressive treatment is only used for cases that do not resolve or when the lesions become infected.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

9. A school-age child has been prescribed magic mouthwash for gingival herpes simplex type I (HSV-1) infection. The parent asks how this helps the childs condition. Which response by the nurse is the most appropriate?
A. Decreases the pain so the child can eat and drink
B. Kills the virus causing the infection by suffocation
C. Prevents secondary infection of the gingiva
D. Shortens the duration of the outbreak
ANS: A
Magic mouthwash has several recipes, but common ingredients include Benadryl, lidocaine, and Mylanta, which all help increase comfort so the child continues to eat and drink. It does not kill the virus, prevent secondary infection, or shorten the duration of the outbreak.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

10. A teen has been taking griseofulvin (Fulvicin) for a fungal skin and scalp condition and reports that it is not working. Which action by the nurse is the most important?
A. Assess for noncompliance with the regimen.
B. Discuss changing medications with the provider.
C. Prepare to administer the drug as an injection.
D. Tell the teen it takes nearly 6 months to work.
ANS: A
The nurse should assess the teen for compliance with the medication regimen, because it takes at least 6 weeks for this medication to work. Due to the lengthy treatment time and the fact that teens are often noncompliant, this would be the nurses first step. If the medication has been used appropriately, discussing a change would be correct. This drug is not give via IM injection.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

11. A child has blood testing for possible atopic dermatitis. The parent asks why testing for IgE is done. Which response by the nurse is the most appropriate?
A. High levels of IgE from an overactive immune system are treated with steroids.
B. If we can control the levels of IgE, we can control your childs skin condition.
C. IgE is raised in allergies and asthma, which are often seen with atopic dermatitis.
D. These results will help us determine how your childs immune system is functioning.
ANS: C
Atopic dermatitis is often seen in children with allergies and asthma. In those conditions, levels of IgE are elevated, so this correlation helps confirm the diagnosis if it is in question. The other answers are inaccurate.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

12. A student is learning about cutaneous skin reactions. Which description is correct?
A. Blistering: heat-related
B. Exanthema: an eruption
C. Pustular: contagious
D. Urticarial: round patches
ANS: B
An examthema is an eruption. Blistering is swelling. Pustular is raised and filled with white blood cells. Urticarial is itching.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

13. A child presents to the emergency department with cutaneous manifestations of an allergic response. Which nursing diagnosis takes priority?
A. Altered comfort related to itching lesions
B. Impaired tissue integrity related to lesions
C. Knowledge deficit related to unknown condition
D. Risk for impaired airway secondary to edema
ANS: D
Usually, actual nursing diagnoses take priority over risk for diagnoses, but in this case, risk for impaired airway is the priority. The childs airway can quickly become compromised due to laryngeal edema. The nurse places priority on frequent assessments of the childs airway. The other diagnoses are relevant, but not as important as the potential for compromised airway.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Planning
Difficulty: Moderate

PTS: 1

14. A 20-lb (9-kg) child is having a severe allergic reaction. The school nurse has an EpiPen Jr. auto-injector containing 0.3 mg. Which action by the nurse is the most appropriate?
A. Administer the injection.
B. Begin CPR.
C. Call 911 immediately.
D. Give half the injection.
ANS: C
EpiPen Jr. auto-injectors are available in two strengths: 0.15 mg for children weighing up to 33 lb (15 kg) and one containing 0.3 mg for older children and adults. The nurse has the wrong-size injector. The most appropriate action is to call 911 to access the emergency medical system. The child does not need CPR. Because the injector is automated, you cannot change the amount that is given.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

15. A parent calls the pediatric clinic asking for advice on treating lice. The child has already been treated once with lindane (Qwell). Which advice from the nurse is the most appropriate?
A. Be sure you are cleaning your house and linens well.
B. Qwell is usually effective after two or three treatments.
C. Switch to malathion (Ovide) and see if that works better.
D. There are some oral medications your child can try.
ANS: C
Ovide is a safe, nontoxic lice shampoo that is very efficacious. The mother should not be told to use Qwell again; the FDA has a black box warning against using this as a first-line drug and the American Academy of Pediatrics no longer recommends it at all. There are oral medications that can be used on resistant lice, but the parent needs to try another shampoo first. Cleaning is important, but not as important as treating the lice.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

16. A child has been diagnosed with scabies and the parents are taught about the use of 5% permethrin lotion (Elimite). Which statement by the parents indicates the need for further instruction?
A. Elimite goes from the nape of the neck to the toes, except on the genitals.
B. The lotion is left on until the next day, when a bath is given.
C. This treatment will have to be repeated 1 week after the first.
D. We will give our child a warm soapy bath before applying the lotion.
ANS: B
Elimite is left on for 8 to 14 hours and then must be removed. The other statements show good understanding.

Cognitive Level: Evaluation/Evaluating
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Evaluation
Difficulty: Moderate

PTS: 1

17. What important safety measure regarding the use of insect repellents does the nurse teach a parenting group?
A. Apply repellents to the childs clothing.
B. There are no substitutes for DEET.
C. Use oil of lemon eucalyptus on babies.
D. Wash repellent off after 2 hours.
ANS: A
Insect repellents are harsh chemicals and should be applied to the clothing of children. Spraying the product on the adults hands and then spreading it on the face and head and exposed skin is an acceptable ways of applying insecticide to a limited amount of skin. The CDC has recently recognized some insecticides that do not contain DEET. Oil of lemon eucalyptus is safe on children over the age of 3. Although insecticides should not stay on for long periods of time, there is no strict 2-hour limit.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

18. A child is in the emergency department (ED) with a dog bite. After cleansing the wound and attending to the childs comfort, which action should the nurse perform next?
A. Give a dose of antibiotic.
B. Offer the child a toy to play with.
C. Provide discharge teaching.
D. Report the bite to authorities.
ANS: D
Animal bites are reportable injuries. The nurse has an obligation to report the bite as soon as he or she is able, as the animal control authorities may want to interview the child and parents quickly. Antibiotics are not warranted in all dog bites. Discharge teaching should be provided when the family is done in the ED. Offering the child a toy is a nice gesture that could be considered a comfort measure, but does not take priority over a legal requirement.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

19. The pediatric nurse knows that which child is most likely to bite another?
A. Adolescent, due to increased anger
B. No specific group is at higher risk.
C. School-aged child, due to frustration
D. Toddler, due to lack of verbal ability
ANS: D
Toddlers are more prone to biting due to the frustration of not being able to verbalize their feelings.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

20. A child who was visiting a wooded area on vacation presents to the doctors office with a localized bulls-eye rash. Which action by the nurse is the most appropriate?
A. Advise parents that treatment depends on laboratory results.
B. Assess for cardiac and neurological involvement.
C. Facilitate admission to a nearby hospital.
D. Teach the parents about cefuroxime (Ceftin).
ANS: D
This child may have early Lyme disease, which is treated presumptively with Ceftin prior to obtaining laboratory results. By the time carditis and neurological involvement occur, the rash has generalized. Admission is not warranted.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Easy

PTS: 1

21. The clinic nurse is assessing a child who had a tick bite for tick-borne disease. What assessment finding indicates to the nurse the child may have Rocky Mountain Spotted Fever and not Lyme disease?
A. Abdominal pain
B. Clear skin
C. Fever
D. Headache
ANS: A
Rocky Mountain Spotted Fever produces severe abdominal pain. Fever and headache are seen in both diseases, as is a rash.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

22. A nurse is providing anticipatory guidance to a community parent group about burn prevention. When discussing school-age and older children, which cause of burn occurs most often in this age group?
A. Cooking and kitchen activities
B. Exposure to hot water
C. Household electrical wires
D. Touching hot appliances
ANS: A
School-age and adolescent children are more independent than younger children and often cook food on the stove, in the oven, or in the microwave. This activity is associated with a risk for burns not seen in younger children. The other activities usually cause burns in infants and toddlers.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

23. When teaching a parenting group how to prevent the most common cause of childhood burns, what action does the nurse advise?
A. Cover electrical outlets.
B. Keep children out of the kitchen.
C. Install smoke detectors.
D. Lock up household chemicals.
ANS: C
The most common type of childhood burn is a thermal burn. Installing smoke detectors provides early warning and the chance to escape a fire.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

24. The nurse working in a pediatric burn unit explains to new registered nurses that which is the most common cause of death in burned children?
A. Hypovolemic shock
B. Infection
C. Sepsis
D. Thrombotic events
ANS: B
About 75% of burn mortality is related to infection.

Cognitive Level: Knowledge/Comprehension
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

25. A child who is intubated and on a mechanical ventilator is being transferred from the emergency department to the burn unit. Which action by the nurse takes priority?
A. Ensure an Ambu bag is at the bedside.
B. Have sedation available if needed.
C. Orient the family to the burn unit.
D. Place the patient on protective isolation.
ANS: A
Maintaining a patent airway is the priority in this child. The nurse should make sure an Ambu bag is at the bedside and that other emergency equipment is available. Sedation may be needed. Orienting the family is important but is not the priority. There is no indication that the child needs protective isolation.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

26. A burned patient had an escharotomy on the right anterior thigh. Which assessment finding indicates that this procedure has been effective?
A. Absence of infection in the burn
B. Compartment pressure of 42 mm Hg
C. Decreased pain in the right leg
D. Pedal pulses 3+/4+ bilaterally
ANS: D
An escharotomy is performed when eschar impedes circulation. Strong and equal pedal pulses indicate return of circulation. Escharotomies are not related to preventing infection. A compartment pressure greater than 30 mm Hg requires emergency surgery. Decreased pain is usually the finding when eschar is present and intact.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

27. A child has been in the burn unit for 13 days. Which nursing assessment indicates that a priority goal has been met?
A. Decreased albumen over 5 days
B. Intake equals output for 24 hours
C. Participates in dressing changes
D. Weight gain of 0.5 kg in 1 week
ANS: D
Nutrition is an important problem for the child with burns, as the child is hypermetabolic and needs a high-calorie, high-protein diet. Children are generally weighed twice a week in the burn center. A weight gain shows that nutritional needs are being met. Albumen should increase with improved nutrition, but remember that this laboratory value lags behind other indicators of nutrition. Participating in dressing changes shows evidence of meeting a psychosocial goal, but that would not take priority over a physical problem. Intake should be more than output because of the insensible losses.

Cognitive Level: Evaluation/Evaluating
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Basic Care and Comfort
Integrated Process: Nursing Process: Evaluation
Difficulty: Moderate

PTS: 1

28. A child is brought to the emergency department from a house fire. She has singed eyebrows and sounds hoarse. After applying oxygen, which action by the nurse takes priority?
A. Assemble intubation equipment.
B. Gently cleanse any burn wounds.
C. Place child on a cardiac monitor.
D. Prepare to give pain medication.
ANS: A
All actions are appropriate for this child; however, airway patency is always the priority. This child has manifestations that cause the nurse to consider an inhalation injury. Swelling can occur rapidly, cutting off the airway. The nurse applies oxygen and ensures intubation supplies are nearby. If needed, the nurse delegates this activity. The child should be placed on a cardiac monitor, but because this is not related to airway, this is not the priority. Pain medication will be an important intervention, as is burn care, but, again, they are not the priority over airway.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

29. Paramedics bring a child to the emergency department with possible hypothermia. He walked to school without a coat and upon arrival he is noted to be shivering, nauseated, and uncoordinated. After removing the childs clothing, what nursing intervention does the nurse plan to implement?
A. Administer rapid IV boluses.
B. Apply a Bair Hugger.
C. Cover the child with warm blankets.
D. Start dialysis with warmed solution.
ANS: C
These are manifestations of mild hypothermia in which the childs temperature will be 3537C (9598.6F). After removing the cold and/or wet clothing, the nurse covers the child with warm blankets and administers warmed O2 and warmed IV solutions. Rapid IV boluses are not indicated. The Bair Hugger would be used in more severe hypothermia, as would dialysis.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

30. A student nurse is caring for an adolescent with frostbite of the hand in the emergency department. Which action by the student would require the registered nurse to intervene?
A. Applies warm blankets to the child
B. Has the teen wear a warmed gown
C. Rubs patients fingers to warm them
D. Takes teens watch off of his wrist
ANS: C
A frostbitten area is never rubbed or massaged, as the ice crystals in the capillaries will damage the tissue when they break out of the vascular beds. Warm blankets and gown are appropriate for general re-warming measures. The watch (and any rings) should be removed in case of swelling.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Easy

PTS: 1

31. A nurse is caring for four patients on a general pediatric unit. The nurse identifies risk for impaired skin integrity as a nursing diagnosis for all four. Which patients skin should the nurse assess first?
A. Adolescent 4 hours postoperative after appendectomy
B. School-age child just back from a tonsillectomy
C. Teen eating in a chair 1 week post-burn
D. Toddler with broken femur in skeletal traction
ANS: D
Immobility is a major risk factor for impaired skin integrity. The nurse should first assess the child in traction, as this child is the least mobile. A child sitting in a chair to eat is at least partially mobile. Children after routine surgery are expected to recover quickly and begin activity within a day.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

32. A nurse assesses a pressure ulcer on a child and finds full-thickness loss of the dermal layer and visible subcutaneous fat. At which stage does the nurse document this pressure ulcer to be?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
ANS: C
A stage III pressure ulcer involves the full thickness of the dermis, possible visible subcutaneous fat, possible sloughing, and possible tunneling. This is a stage III ulcer.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

33. A student is caring for a burned child on the burn unit. The student is performing burn care. Which action by the student requires intervention by the registered nurse?
A. Applies silver nitrate (0.5% AgNO3) to the childs face
B. Applies silver sulfadiazine (AgSD) to the childs face
C. Checks electrolyte levels before applying silver nitrate
D. Uses Sulfamylon (mafenide acetate) on childs ear burns
ANS: A
Silver nitrate cannot be used on the face. The other actions are appropriate.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Intervention
Difficulty: Difficult

PTS: 1

34. A nurse is preparing to administer a prn medication to a 6-year-old child for pruritus. Which order should the nurse question?
A. Chlorpheniramine (Chlor-Trimeton) 2 mg every 6 hours with food
B. Cyproheptadine (Periactin) 24 mg every 812 hours
C. Diphenhydramine (Benadryl) 50 mg PO every 46 hours
D. Hydroxyzine (Atarax) 2 mg/kg/day in divided doses every 68 hours
ANS: C
For a child 6 to 12 years of age, the dose of Benadryl is 12.525 mg every 46 hours, not to exceed 150 mg/day. The other doses are appropriate.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

35. A nurse has assessed the skin of a newborn with the AWHONN Neonatal Skin Condition Score Tool and determines that her patient has a score of 3. What action by the nurse is most appropriate?
A. Document the findings and continue to monitor.
B. Elevate the childs lower extremities on pillows.
C. Implement pressure ulcer prevention measures.
D. Request a consultation by the wound care nurse.
ANS: A
This is a perfect score using this tool. The nurse should document the findings and continue to monitor per agency protocol. None of the other actions is required.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

36. A nurse wishes to prevent radiant heat loss from an infant. What action is the most appropriate?
A. Apply warm blankets to the baby.
B. Cover the babys head with a cap.
C. Place a space heater near the baby.
D. Warm and humidify the oxygen.
ANS: B
Radiant heat loss occurs as warmth dissipates into the environment, often occurring rapidly and accounting for over 50% of infant heat loss. The nurse covers the babys head with a cap. Warm blankets would warm the baby through conduction. A space heater provides convection. Breathing warmed oxygen is preventing heat loss through respiration.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Basic Care and Comfort
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

MULTIPLE RESPONSE

1. The student studying pediatric integumentary problems learns that which are functions of the skin? (Select all that apply.)
A. Assists in water retention
B. Initiates tactile sensations
C. Provides physical barrier
D. Regulates temperature set point
E. Synthesizes vitamin D
ANS: A, B, C, E
The skin serves many functions, including forming a physical barrier to protect the body; initiating the sensations of touch, pain, heat, and cold; helping to regulate temperature; synthesizing vitamin D; and aiding in water retention. The temperature set point is regulated by the hypothalamus.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

2. The nurse working in a community pediatric clinic knows that which are examples of secondary skin lesions? (Select all that apply.)
A. Crusts
B. Scales
C. Scars
D. Ulcers
E. Wheals
ANS: A, B, C, D
Secondary lesions are the result of changes from primary lesions and include crusts, scales, scars, ulcers, lichenification, keloids, fissures, and erosions. A wheal is a primary lesion.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

3. The faculty member explains fungal skin diseases to a group of students. Which are the common types of this disorder? (Select all that apply.)
A. Tinea capitis
B. Tinea corporis
C. Tinea cruris
D. Tinea manus
E. Tinea pedis
ANS: A, B, C, E
The common integumentary fungal infections include tinea capitis (scalp), tinea corporis (ringworm), tinea cruris (jock itch), and tinea pedis (athletes foot). Tinea manus is not a type of fungal infection.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

4. A nurse is teaching a community parent group about signs and symptoms of Lyme disease. Which statements does the nurse include? (Select all that apply.)
A. Bulls-eye rash is seen in the early stage of the disease.
B. Fatigue and headache frequently occur in the early stage.
C. Inability to bear weight is often seen in the late disease phase.
D. Lyme disease manifests 330 days after a tick bite.
E. Signs of meningitis are seen in the early disseminated phase.
ANS: A, B, D, E
The early localized stage includes a rash (often classified as a bulls-eye rash) and vague systemic symptoms such as fatigue, headache, arthralgia, neck pain, fever, and myalgia. In the early disseminated phase, the rash expands; fatigue, headache, and arthralgia become more common; and the child may develop cranial nerve palsy, meningitis, and carditis. In the late disease phase, arthritis occurs that migrates from joint to joint, making walking uncomfortable, but the child is still able to bear weight.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

COMPLETION

1. A child weighing 110 lb (50 kg) was involved in a car fire at 3 p.m. She did not reach the emergency department until 5 p.m. She suffered burns over 45% of her body. How fast does the nurse program the IV pump in order to deliver the first 50% of her fluid requirements? Using the standard Parkland formula, the nurse should program the IV pump at ____________________ mL/hour.

ANS:
750
50 x 4 x 45 = 9,000 mL needed in 24 hours
50% of 9,000 = 4,500 mL in the first 8 hours from the time of the burn
Two hours have passed since the time of the burn, so this amount needs to be infused in the remaining 6 hours: 4500/6 = 750 mL.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

2. A child weighing 123 lb (56 kg) has been diagnosed with Rocky Mountain Spotted Fever. The nurse calculates that the correct dose, to be given twice a day, is ____________________.

ANS:
100 mg
The dose for children weighing more than 45 kg is 2.2 mg/kg/dose twice daily, with a maximum dose of 100 mg twice daily. At 56 kg the dose is calculated to be 123 mg, but because the maximum dose is 100 mg, this is what the nurse administers.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

3. An adolescent is in the emergency department with partial-thickness burns covering his right anterior thigh, his abdomen, and his right anterior arm. The nurse calculates the total body surface area (TBSA) burned as ____________________.

ANS:
13.5 %
Using the Rule of 9s on this adolescent, the right anterior thigh is 9%, the abdomen is approximately 9% (half of 18% for the anterior torso), and the right anterior arm is 4.5%.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

4. A 10-year-old child is in the emergency department with burns on her buttocks, the backs of her thighs, and the soles of her feet. The nurse calculates this childs total body surface area (TBSA) burned as ____________________.

ANS:
17.5%
Using the Lund and Browder chart for this child, the buttocks are a total of 5%, the backs of the thighs are 4.5% each (total 9%), and the soles of the feet are 1.75% each (3.5% total). This equals 17.5%.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

5. A child weighing 34 kg (74.8 lb) has a burn encompassing 35% total body surface area (TBSA). Using the standard Parkland formula, the nurse calculates the childs initial 24-hour fluid requirement to be ____________________mL.

ANS:
4,760
34 x 4 x 35 = 4,760.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

Leave a Reply