Chapter 47: Integumentary Dysfunction Nursing School Test Banks

Chapter 47: Integumentary Dysfunction

MULTIPLE CHOICE

1. 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.

PTS: 1 DIF: Cognitive Level: Application REF: 1496

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

2. 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.

PTS: 1 DIF: Cognitive Level: Application REF: 1496

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

3. 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 Woods 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 Woods lamp is used to detect fluorescent materials in the skin and hair. It is used in certain disease states such as tinea capitis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1498

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

4. The nurse is teaching parents of a 3-year-old with impetigo that they can anticipate:

a.

No scarring.

c.

Slightly depressed scars.

b.

Pigmented spots.

d.

Atrophic white scars.

ANS: A

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

PTS: 1 DIF: Cognitive Level: Application REF: 1499

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

5. 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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1499

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

6. Lymphangitis (streaking) is frequently seen in:

a.

Cellulitis.

c.

Impetigo contagiosa.

b.

Folliculitis.

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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1499

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

7. The nurse should expect to assess which causative agent in a child who has warts?

a.

Bacteria

c.

Parasite

b.

Fungus

d.

Virus

ANS: D

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

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1498

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

8. Which primary treatment will the nurse implement for a child with warts?

a.

Vaccination

c.

Corticosteroids

b.

Local destruction

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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1495

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

9. 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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1500

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

10. 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

c.

Oral antiviral agent

b.

Oral griseofulvin

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.

PTS: 1 DIF: Cognitive Level: Application REF: 1500

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

11. Ringworm, frequently found in schoolchildren, is caused by:

a.

Virus.

c.

Allergic reaction.

b.

Fungus.

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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1493

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

12. Matts mother tells the nurse that he keeps scratching the areas where he has poison ivy. The nurses 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.

PTS: 1 DIF: Cognitive Level: Application REF: 1503

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

13. The primary clinical manifestation of scabies is:

a.

Edema.

c.

Pruritus.

b.

Redness.

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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1505

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

14. The only symptom of pediculosis capitis (head lice) is usually:

a.

Itching.

c.

Scalp rash.

b.

Vesicles.

d.

Localized inflammatory response.

ANS: 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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1507

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

15. The management of a child who has just been stung by a bee or wasp should include the application of:

a.

Cool compresses.

c.

Antibiotic cream.

b.

Warm compresses.

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.

PTS: 1 DIF: Cognitive Level: Application REF: 1507

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

16. A 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.

PTS: 1 DIF: Cognitive Level: Application REF: 1505

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

17. 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.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1505

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

18. 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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1507

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

19. 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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1510

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

20. 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.

c.

Urine and feces.

b.

Candida albicans.

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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1513

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

21. 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 infants 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 infants buttocks with soap before applying a thin layer of oil.

d.

I will apply baby oil and powder to the creases in my infants 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.

PTS: 1 DIF: Cognitive Level: Application REF: 1513

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

22. 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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1514

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

23. 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 infants 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.

PTS: 1 DIF: Cognitive Level: Application REF: 1514

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

24. 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.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1517

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

25. 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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1517

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

26. 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 possible

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.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1529

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

27. 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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1518

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

28. A child is admitted with extensive burns. The nurse notes that there are burns on the childs lips and singed nasal hairs. The nurse should suspect that the child has:

a.

A chemical burn.

c.

An electrical burn.

b.

An inhalation injury.

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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1519

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

29. 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.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1521

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

30. The most immediate threat to life in children with thermal injuries is:

a.

Shock.

c.

Local infection.

b.

Anemia.

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.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1521

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

31. After the acute stage and during the healing process, the primary complication from burn injury is:

a.

Asphyxia.

c.

Renal shutdown.

b.

Shock.

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.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1521

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

32. 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.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1521

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

33. 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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1521

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

34. 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.

PTS: 1 DIF: Cognitive Level: Application REF: 1523

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

35. Fentanyl and midazolam (Versed) are given before debridement of a childs 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.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1523

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

36. A child with extensive burns requires debridement. The nurse should anticipate that a priority goal related to this procedure is to:

a.

Reduce pain.

c.

Maintain airway.

b.

Prevent bleeding.

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.

PTS: 1 DIF: Cognitive Level: Application REF: 1523

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

37. 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.

PTS: 1 DIF: Cognitive Level: Application REF: 1523

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

38. One of the first signs of overwhelming sepsis in a child with burn injuries is:

a.

Seizures.

c.

Disorientation.

b.

Bradycardia.

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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1526

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

39. 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.

PTS: 1 DIF: Cognitive Level: Application REF: 1526

OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

40. An important consideration for the nurse when changing dressings and applying topical medication to a childs 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.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1526

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

41. 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 infants 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 infants skin should be exposed even for short time periods. Sunscreens should not be used extensively on infants younger than 6 months.

PTS: 1 DIF: Cognitive Level: Application REF: 1529

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

42. To best assess the child with severe burns for adequate perfusion, the nurse monitors:

a.

Distal pulses.

c.

Urine output.

b.

Skin turgor.

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.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1522

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

43. Which nursing intervention is the highest priority in the initial care of a child with a major burn injury?

a.

Establishing and maintaining the childs 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 childs 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.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1519

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

44. 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 Burows 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 Burows solution are not effective in fungal infections.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1501

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

45. 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 childs hair short; lice infest short hair as well as long. It increases the childs 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.

PTS: 1 DIF: Cognitive Level: Application REF: 1507

OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

46. 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.

PTS: 1 DIF: Cognitive Level: Application REF: 1512

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

47. Hydrotherapy is required to treat a child with extensive partial-thickness burn wounds. Which is the primary purpose of hydrotherapy?

a.

Debride the wounds.

c.

Provide pain relief.

b.

Increase peripheral blood flow.

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.

PTS: 1 DIF: Cognitive Level: Application REF: 1523

OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

48. 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).

PTS: 1 DIF: Cognitive Level: Application REF: 1511

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

MULTIPLE RESPONSE

49. 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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1514

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

50. 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 infants 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.

PTS: 1 DIF: Cognitive Level: Application REF: 1514

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

51. 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.

PTS: 1 DIF: Cognitive Level: Application REF: 1528

OBJ: Nursing Process: Teaching/Learning

MSC: Client Needs: Physiologic Integrity

52. 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.

PTS: 1 DIF: Cognitive Level: Application REF: 1508

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

COMPLETION

53. A nurse is caring for a 5-year-old child with a major burn. The health care provider has written a prescription to notify the health care provider if urine output falls to or below 2 mL/kg/hr. The child weighs 55 lb. The nurse should notify the health care provider if the milliliters of urine output is at or below _____ for an hour. Record your answer as a whole number.

ANS:

50

To calculate the childs weight in kilograms, the weight in pounds is divided by 2.2. That number is then multiplied by 2 to get the amount expected for a 1-hour period: 55/2.2 = 25 kg; 25 kg 2 mL = 50 mL/hr.

The primary emphasis during the emergent phase is the treatment of burn shock and the management of pulmonary status. Monitoring vital signs, output, fluid infusion, and respiratory parameters are ongoing activities in the hours immediately after injury. Intravenous infusion is begun immediately and is regulated to maintain a urinary output of at least 1 to 2 mL/kg in children weighing less than 30 kg (66 pounds).

PTS: 1 DIF: Cognitive Level: Analysis REF: 1525

OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

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