The Child with an Integumentary Alteration

MULTIPLE CHOICE

1. What should be included in teaching a parent about the management of small red macules and vesicles that become pustules around the child’s mouth and cheek?

a.
Keep the child home from school for 24 hours after initiation of antibiotic treatment.
b.
Clean the rash vigorously with Betadine three times a day.
c.
Notify the physician for any itching.
d.
Keep the child home from school until the lesions are healed.

ANS: A

To prevent the spread of impetigo to others, the child should be kept home from school for 24 hours after treatment is initiated. Good hand washing is imperative in preventing the spread of impetigo. The lesions should be washed gently with a warm soapy washcloth three times a day. Washcloth should not be shared with other members of the family. Itching is common and does not necessitate medical treatment. Rather, parents should be taught to clip the child’s nails to prevent maceration of the lesions. The child may return to school 24 hours after initiation of antibiotic treatment.

DIF: Cognitive Level: Comprehension REF: p. 634

OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance

2. When taking a history of a child with cellulitis, which information would be most pertinent for the nurse to assess?

a.
Any medication the child is taking
b.
Enlarged, mobile, and nontender lymph nodes
c.
Child’s urinalysis results
d.
Recent infections or signs of infection

ANS: D

Cellulitis may follow an upper respiratory infection, sinusitis, otitis media, or a tooth abscess. The affected area is red, hot, tender, and indurated. Medication history is important, but the history of recent infections is more relevant to the diagnosis. Lymph nodes may be enlarged (lymphadenitis), but they are not mobile and are nontender. Lymphangitis may be seen, with red “streaking” of the surrounding area. An abnormal urinalysis result is not usually associated with cellulitis.

DIF: Cognitive Level: Comprehension REF: p. 635

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

3. Which statement made by a parent indicates an understanding about the management of a child with cellulitis?

a.
“I am supposed to continue the antibiotic until the redness and swelling disappear.”
b.
“I have been putting ice on my son’s arm to relieve the swelling.”
c.
“I should call the doctor if the redness disappears.”
d.
“I have been putting a warm soak on my son’s arm every 4 hours.”

ANS: D

Warm soaks applied every 4 hours while the child is awake increase circulation to the infected area, relieve pain, and promote healing. The parent should not discontinue antibiotics when signs of infection disappear. To ensure complete healing, the parent should understand that the entire course of antibiotics should be given as prescribed. A warm soak is indicated for the treatment of cellulitis. Ice will decrease circulation to the affected area and inhibit the healing process. The disappearance of redness indicates healing and is not a reason to seek medical advice.

DIF: Cognitive Level: Application REF: p. 635

OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance

4. What should the parents of an infant with thrush (oral candidiasis) be taught about medication administration?

a.
Give nystatin suspension with a syringe without a needle.
b.
Apply nystatin cream to the affected area twice a day.
c.
Give nystatin just before the infant is fed.
d.
Rub nystatin suspension onto the oral mucous membranes with a gloved finger after feedings.

ANS: D

It is important to apply the nystatin suspension to the affected areas, which is best accomplished by rubbing it onto the gums and tongue, after feedings, every 6 hours, until 3 to 4 days after symptoms have disappeared. Medication may not reach the affected areas when it is squirted into the infant’s mouth. Rubbing the suspension onto the gum ensures contact with the affected areas. Nystatin cream is used for diaper rash caused by Candida. To prolong contact with the affected areas, the medication should be administered after a feeding.

DIF: Cognitive Level: Application REF: p. 636

OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance

5. What beverage should the parents of a child with ringworm be taught to give along with the prescribed griseofulvin (Fulvicin)?

a.
Water
b.
A carbonated drink
c.
Milk
d.
Fruit juice

ANS: C

Griseofulvin is insoluble in water. Giving the medication with a high-fat meal or milk increases absorption. Carbonated drinks do not contain fat, which aids in the absorption of griseofulvin. Fruit juice does not contain any fat; fat aids absorption of the medication.

DIF: Cognitive Level: Application REF: p. 639

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

6. Which assessment is applicable to the care of a child with herpetic gingivostomatitis?

a.
Comparison of range of motion for the upper and lower extremities
b.
Urine output, mucous membranes, and skin turgor
c.
Growth pattern since birth
d.
Bowel elimination pattern

ANS: B

The child with herpetic gingivostomatitis is at risk for fluid volume deficit. Painful lesions on the mouth make drinking unpleasant and undesirable, with subsequent dehydration becoming a real danger. An oral herpetic infection does not affect joint function. Herpetic gingivostomatitis is not a chronic disorder that would affect the child’s long-term growth pattern. Although constipation could be caused by dehydration, it is more important to assess urine output, skin turgor, and mucous membranes to identify dehydration before constipation is a problem.

DIF: Cognitive Level: Comprehension REF: p. 641

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

7. Parents of the child with lice infestation should be instructed carefully in the use of antilice products because of which potential side effect?

a.
Nephrotoxicity
b.
Neurotoxicity
c.
Ototoxicity
d.
Bone marrow depression

ANS: B

Because of the danger of absorption through the skin and potential for neurotoxicity, antilice treatment must be used with caution. A child with many open lesions can absorb enough to cause seizures. Antilice products are not known to be nephrotoxic or ototoxic. Products that treat lice are not known to cause bone marrow depression.

DIF: Cognitive Level: Application REF: p. 642

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

8. When assessing the child with atopic dermatitis, the nurse should ask the parents about a history of which problem?

a.
Asthma
b.
Nephrosis
c.
Lower respiratory tract infections
d.
Neurotoxicity

ANS: A

Most children with atopic dermatitis have a family history of asthma, hay fever, or atopic dermatitis and up to 80% of children with atopic dermatitis have asthma or allergic rhinitis. Complications of atopic dermatitis relate to the skin. The renal system is not affected by atopic dermatitis. There is no link between lower respiratory tract infections and atopic dermatitis. Atopic dermatitis does not have a relationship to neurotoxicity.

DIF: Cognitive Level: Comprehension REF: p. 630

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

9. What should the nurse teach an adolescent who is taking tretinoin (Retin-A) for treatment acne?

a.
The medication should be taken with meals.
b.
Apply sunscreen before going outdoors.
c.
Wash with benzoyl peroxide before application.
d.
The effect of the medication should be evident within 1 week.

ANS: B

Tretinoin causes photosensitivity and sunscreen should be applied before sun exposure. Tretinoin is a topical medication. Application is not affected by meals. If applied together, benzoyl peroxide and tretinoin have reduced effectiveness and a potentially irritant effect. Optimal results from tretinoin are not achieved for 3 to 5 months.

DIF: Cognitive Level: Application REF: p. 645

OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance

10. When changing an infant’s diaper, the nurse notices small bright red papules with satellite lesions on the perineum, anterior thigh, and lower abdomen. This rash is characteristic of which condition?

a.
Primary candidiasis
b.
Irritant contact dermatitis
c.
Intertrigo
d.
Seborrheic dermatitis

ANS: A

Small red papules with peripheral scaling in a sharply demarcated area involving the anterior thighs, lower abdomen, and perineum are characteristic of primary candidiasis. A shiny, parchment-like erythematous rash on the buttocks, medial thighs, mons pubis, and scrotum, but not in the folds, is suggestive of irritant contact dermatitis. Intertrigo is identified by a red macerated area of sharp demarcation in the groin folds. It can also develop in the gluteal and neck folds. Seborrheic dermatitis is recognized by salmon-colored, greasy lesions with a yellowish scale found primarily in skin-fold areas or on the scalp.

DIF: Cognitive Level: Analysis REF: p. 636

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

11. The depth of a burn injury may be classified as:

a.
localized or systemic.
b.
superficial, superficial partial thickness, deep partial thickness, or full thickness.
c.
electrical, chemical, or thermal.
d.
minor, moderate, or major.

ANS: B

The vocabulary to classify the depth of burn is superficial, partial thickness, or full thickness. These terms refer to the effect of the burn injury. For example, is there a reaction in the area of the burn (localized) or throughout the body (systemic)? Electrical, chemical, or thermal are terms that refer to the cause of the burn injury. Minor, moderate, or major are terms that refer to the severity of the burn injury.

DIF: Cognitive Level: Comprehension REF: p. 651

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

12. What is the major difference between caring for an infant with burns and an adolescent with burns?

a.
An increased risk of cardiovascular problems in the infant
b.
A decreased need for caloric intake in the infant
c.
An increased risk for hypervolemia in the adolescent
d.
A decreased need for electrolyte replacement in the infant

ANS: A

The higher proportion of body fluid to body mass in infants increases the risk of cardiovascular problems because of a less effective cardiovascular response to changing intravascular volume. Infants are at an increased risk for protein and calorie deficiency because they have smaller muscle mass and lower body fat. Hypovolemia is a risk for all burn patients; however, the risk is higher for the infant than for the adolescent. There is an increased risk for electrolyte loss in the infant because of the larger body surface area.

DIF: Cognitive Level: Comprehension REF: p. 650

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

13. Which procedure is contraindicated in the care of a child with a minor partial-thickness burn injury wound?

a.
Cleaning the affected area with mild soap and water
b.
Applying antimicrobial ointment to the burn wound
c.
Changing dressings daily
d.
Leaving all loose tissue or skin intact

ANS: D

All loose skin and tissue should be debrided because it can become a breeding ground for infectious organisms. Cleaning with mild soap and water is important to the healing process. Antimicrobial ointment is used on the burn wound to fight infection. Clean dressings are applied daily to prevent wound infection. When dressings are changed, the condition of the burn wound can be assessed.

DIF: Cognitive Level: Comprehension REF: p. 653

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

14. The process of burn shock continues until which physiological mechanism occurs?

a.
Heart rate returns to normal.
b.
Airway swelling decreases.
c.
Body temperature regulation returns to normal.
d.
Capillaries regain their seal.

ANS: D

Within minutes of the burn injury, the capillary seals are lost with a massive fluid leakage into the surrounding tissue, resulting in burn shock. The process of burn shock continues for approximately 24 to 48 hours, when capillary seals are restored. The heart rate will be increased throughout the healing process because of increased metabolism. Airway swelling subsides over a period of 2 to 5 days after injury. Body temperature regulation will not be normal until healing is well under way.

DIF: Cognitive Level: Comprehension REF: p. 655

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

15. To assess the child with severe burns for adequate perfusion, the nurse monitors which area?

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.

DIF: Cognitive Level: Analysis REF: p. 655

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

16. Which medication would be best for the nurse to administer before a dressing change for the severely burned child?

a.
Codeine
b.
Benadryl
c.
Morphine
d.
Acetaminophen

ANS: C

Morphine is the drug of choice for pain management in the severely burned child. It should be administered intravenously. Codeine may be used to diminish pain between dressing changes. Benadryl is administered to relieve discomfort from itching. Acetaminophen can be given for discomfort between painful procedures.

DIF: Cognitive Level: Application REF: pp. 654-655

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

17. Which nursing assessment and care holds 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 are 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 are 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 are the ABCs.

DIF: Cognitive Level: Analysis REF: p. 655

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

MULTIPLE RESPONSE

1. A nurse is teaching parents about prevention of diaper dermatitis. Which should the nurse include in the teaching plan? Select all that apply.

a.
Clean the diaper area gently after every diaper change with a mild soap.
b.
Use a protective ointment to clean dry intact skin.
c.
Use a steroid cream after each diaper change.
d.
Use rubber or plastic pants over the diaper.
e.
Wash cloth diapers in hot water with a mild soap and double rinse.

ANS: A, B, E

Prompt, gentle cleaning with water and mild soap (Dove, Neutrogena Baby Soap) after each voiding or defecation rids the skin of ammonia and other irritants and decreases the chance of skin breakdown and infection. A bland, protective ointment (A&D, Balmex, Desitin, zinc oxide) can be applied to clean, dry, intact skin to help prevent diaper rash. If cloth diapers are laundered at home, the parents should wash them in hot water, using a mild soap and double rinsing. Occlusion increases the risk of systemic absorption of steroid; thus steroid creams are rarely used for diaper dermatitis because the diaper functions as an occlusive dressing. Rubber or plastic pants increase skin breakdown by holding in moisture and should be used infrequently.

DIF: Cognitive Level: Application REF: p. 630

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

2. A nurse is instructing parents on treatment of pediculosis (head lice). Which should the nurse include in the teaching plan? Select all that apply.

a.
Bedding should be washed in warm water and dried on a low setting.
b.
After treating the hair and scalp with a pediculicide, shampoo the hair with regular shampoo.
c.
Retreat the hair and scalp with a pediculicide in 7 to 10 days.
d.
Items that cannot be washed should be dry cleaned or sealed in plastic bags for 2 to 3 weeks.
e.
Combs and brushes should be boiled in water for at least 10 minutes.

ANS: C, D, E

An over-the-counter pediculicide, permethrin 1% (Nix, Elimite, Acticin), kills head lice and eggs with one application and has residual activity (i.e., it stays in the hair after treatment) for 10 days. Nix Creme Rinse is applied to the hair after it is washed with a conditioner-free shampoo. The product should be rinsed out after 10 minutes. The hair should not be shampooed for 24 hours after the treatment. Even though the kill rate is high and there is residual action, retreatment should occur after 7 to 10 days. Combs and brushes should be boiled or soaked in antilice shampoo or hot water [greater than 60° C (140° F)] for at least 10 minutes. Advise parents to wash clothing (especially hats and jackets), bedding, and linens in hot water and dry at a hot dryer setting.

DIF: Cognitive Level: Application REF: p. 643

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance