Chapter 31 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 6th Edition Test Bank
Chapter 31

Question 1

Type: MCSA

The nurse is planning care for a 3-month-old infant diagnosed with eczema. Which should be the focus of the nurses care for this infant?

1. Maintaining adequate nutrition

2. Keeping the baby content

3. Preventing infection of lesions

4. Applying antibiotics to lesions

Correct Answer: 3

Rationale 1: Nursing care should focus on preventing infection of lesions. Due to impaired skin-barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infections by organisms. Maintaining adequate nutrition and keeping the infant content are not as high a priority. Antibiotics are not routinely applied to the lesions.

Rationale 2: Nursing care should focus on preventing infection of lesions. Due to impaired skin-barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infections by organisms. Maintaining adequate nutrition and keeping the infant content are not as high a priority. Antibiotics are not routinely applied to the lesions.

Rationale 3: Nursing care should focus on preventing infection of lesions. Due to impaired skin-barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infections by organisms. Maintaining adequate nutrition and keeping the infant content are not as high a priority. Antibiotics are not routinely applied to the lesions.

Rationale 4: Nursing care should focus on preventing infection of lesions. Due to impaired skin-barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infections by organisms. Maintaining adequate nutrition and keeping the infant content are not as high a priority. Antibiotics are not routinely applied to the lesions.

Global Rationale: Nursing care should focus on preventing infection of lesions. Due to impaired skin-barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infections by organisms. Maintaining adequate nutrition and keeping the infant content are not as high a priority. Antibiotics are not routinely applied to the lesions.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 31.4 Plan the nursing care for the child with alterations in skin integrity, including dermatitis, infectious disorders, and infestations.

Question 2

Type: MCSA

The nurse is caring for a pediatric client diagnosed with eczema. Which topical medication order does the nurse anticipate for this client?

1. Corticosteroids

2. Retinoids

3. Antifungals

4. Antibacterials

Correct Answer: 1

Rationale 1: Topical corticosteroids are used to reduce inflammation when the child has eczema. Topical retinoids are used for acne. Topical antifungals are used for dermatophytoses. Topical antibacterials would be used for problems such as burns.

Rationale 2: Topical corticosteroids are used to reduce inflammation when the child has eczema. Topical retinoids are used for acne. Topical antifungals are used for dermatophytoses. Topical antibacterials would be used for problems such as burns.

Rationale 3: Topical corticosteroids are used to reduce inflammation when the child has eczema. Topical retinoids are used for acne. Topical antifungals are used for dermatophytoses. Topical antibacterials would be used for problems such as burns.

Rationale 4: Topical corticosteroids are used to reduce inflammation when the child has eczema. Topical retinoids are used for acne. Topical antifungals are used for dermatophytoses. Topical antibacterials would be used for problems such as burns.

Global Rationale: Topical corticosteroids are used to reduce inflammation when the child has eczema. Topical retinoids are used for acne. Topical antifungals are used for dermatophytoses. Topical antibacterials would be used for problems such as burns.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 31.4 Plan the nursing care for the child with alterations in skin integrity, including dermatitis, infectious disorders, and infestations.

Question 3

Type: MCSA

The nurse is examining a 12-month-old who is brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with bright red scaly plaques and small papules. Satellite lesions are also present. What is the most likely cause of this clients diaper rash?

1. Impetigo (staph)

2. Candida albicans (yeast)

3. Urine and feces

4. Infrequent diapering

Correct Answer: 2

Rationale 1: Candida albicans is frequently the underlying cause of severe diaper rash. When a primary or secondary infection with Candida albicans occurs, the rash has bright red scaly plaques with sharp margins. Small papules and pustules may be seen, along with satellite lesions. Even though diaper dermatitis can be caused by impetigo, urine and feces, and infrequent diapering, the lesions and persistent characteristics are common for Candida.

Rationale 2: Candida albicans is frequently the underlying cause of severe diaper rash. When a primary or secondary infection with Candida albicans occurs, the rash has bright red scaly plaques with sharp margins. Small papules and pustules may be seen, along with satellite lesions. Even though diaper dermatitis can be caused by impetigo, urine and feces, and infrequent diapering, the lesions and persistent characteristics are common for Candida.

Rationale 3: Candida albicans is frequently the underlying cause of severe diaper rash. When a primary or secondary infection with Candida albicans occurs, the rash has bright red scaly plaques with sharp margins. Small papules and pustules may be seen, along with satellite lesions. Even though diaper dermatitis can be caused by impetigo, urine and feces, and infrequent diapering, the lesions and persistent characteristics are common for Candida.

Rationale 4: Candida albicans is frequently the underlying cause of severe diaper rash. When a primary or secondary infection with Candida albicans occurs, the rash has bright red scaly plaques with sharp margins. Small papules and pustules may be seen, along with satellite lesions. Even though diaper dermatitis can be caused by impetigo, urine and feces, and infrequent diapering, the lesions and persistent characteristics are common for Candida.

Global Rationale: Candida albicans is frequently the underlying cause of severe diaper rash. When a primary or secondary infection with Candida albicans occurs, the rash has bright red scaly plaques with sharp margins. Small papules and pustules may be seen, along with satellite lesions. Even though diaper dermatitis can be caused by impetigo, urine and feces, and infrequent diapering, the lesions and persistent characteristics are common for Candida.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 31.1 Classify the characteristics of skin lesions caused by irritants, drug reactions, mites, infection, and injury.

Question 4

Type: MCSA

A 2-month-old client has a candidal diaper rash. Which medication does the nurse anticipate will be prescribed for this client?

1. Bacitracin ointment

2. Hydrocortisone ointment

3. Desitin

4. Nystatin given topically and orally

Correct Answer: 4

Rationale 1: Diaper candidiasis is treated with an antifungal cream (Nystatin). An oral antifungal agent may be given to clear the candidiasis from the intestines. Bacitracin is for an infection caused by staphylococcus. Mild diaper rash is treated with a barrier such as Desitin. Moderate diaper rash is treated with hydrocortisone ointment.

Rationale 2: Diaper candidiasis is treated with an antifungal cream (Nystatin). An oral antifungal agent may be given to clear the candidiasis from the intestines. Bacitracin is for an infection caused by staphylococcus. Mild diaper rash is treated with a barrier such as Desitin. Moderate diaper rash is treated with hydrocortisone ointment.

Rationale 3: Diaper candidiasis is treated with an antifungal cream (Nystatin). An oral antifungal agent may be given to clear the candidiasis from the intestines. Bacitracin is for an infection caused by staphylococcus. Mild diaper rash is treated with a barrier such as Desitin. Moderate diaper rash is treated with hydrocortisone ointment.

Rationale 4: Diaper candidiasis is treated with an antifungal cream (Nystatin). An oral antifungal agent may be given to clear the candidiasis from the intestines. Bacitracin is for an infection caused by staphylococcus. Mild diaper rash is treated with a barrier such as Desitin. Moderate diaper rash is treated with hydrocortisone ointment.

Global Rationale: Diaper candidiasis is treated with an antifungal cream (Nystatin). An oral antifungal agent may be given to clear the candidiasis from the intestines. Bacitracin is for an infection caused by staphylococcus. Mild diaper rash is treated with a barrier such as Desitin. Moderate diaper rash is treated with hydrocortisone ointment.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 31.4 Plan the nursing care for the child with alterations in skin integrity, including dermatitis, infectious disorders, and infestations.

Question 5

Type: MCMA

The nurse is teaching a group of adolescents about care for acne vulgaris. Which interventions will the nurse include in the teaching session?

Standard Text: Select all that apply.

1. Wash skin with mild soap and water twice a day.

2. Use astringents and vigorous scrubbing.

3. Avoid picking or squeezing the lesions.

4. Apply tretinoin (Retin-A) liberally.

5. Avoid sun exposure if on tetracycline.

Correct Answer: 1,3,5

Rationale 1: The adolescent should be taught to wash skin with mild soap and water twice a day, to avoid picking or squeezing acne lesions, and to avoid sun exposure if on tetracycline. Using astringents and scrubbing vigorously can exacerbate acne. Tretinoin (Retin-A) should be applied sparingly (pea-size doses).

Rationale 2: The adolescent should be taught to wash skin with mild soap and water twice a day, to avoid picking or squeezing acne lesions, and to avoid sun exposure if on tetracycline. Using astringents and scrubbing vigorously can exacerbate acne. Tretinoin (Retin-A) should be applied sparingly (pea-size doses).

Rationale 3: The adolescent should be taught to wash skin with mild soap and water twice a day, to avoid picking or squeezing acne lesions, and to avoid sun exposure if on tetracycline. Using astringents and scrubbing vigorously can exacerbate acne. Tretinoin (Retin-A) should be applied sparingly (pea-size doses).

Rationale 4: The adolescent should be taught to wash skin with mild soap and water twice a day, to avoid picking or squeezing acne lesions, and to avoid sun exposure if on tetracycline. Using astringents and scrubbing vigorously can exacerbate acne. Tretinoin (Retin-A) should be applied sparingly (pea-size doses).

Rationale 5: The adolescent should be taught to wash skin with mild soap and water twice a day, to avoid picking or squeezing acne lesions, and to avoid sun exposure if on tetracycline. Using astringents and scrubbing vigorously can exacerbate acne. Tretinoin (Retin-A) should be applied sparingly (pea-size doses).

Global Rationale: The adolescent should be taught to wash skin with mild soap and water twice a day, to avoid picking or squeezing acne lesions, and to avoid sun exposure if on tetracycline. Using astringents and scrubbing vigorously can exacerbate acne. Tretinoin (Retin-A) should be applied sparingly (pea-size doses).

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 31.5 Prepare an education plan for adolescents with acne to promote self-care.

Question 6

Type: MCSA

A pediatric client is hospitalized with a severe case of impetigo contagiosa. Which antibiotic does the nurse anticipate the healthcare provider will order for this client?

1. Dicloxacillin (Pathocil)

2. Rifampin (Rifadin)

3. Sulfamethoxazole and trimethoprim (Bactrim)

4. Metronidazole (Flagyl)

Correct Answer: 1

Rationale 1: A systemic antibiotic will be given for severe impetigo because it is a bacterial infection. Dicloxacillin is used in treatment of skin and soft-tissue infections. It is specific for treating staphylococcal infections. Rifampin is an antitubercular agent, sulfamethoxazole and trimethoprim are used as a prophylaxis against Pneumocystis carinii pneumonia (PCP), and metronidazole is used to treat anaerobic and protozoic infections.

Rationale 2: A systemic antibiotic will be given for severe impetigo because it is a bacterial infection. Dicloxacillin is used in treatment of skin and soft-tissue infections. It is specific for treating staphylococcal infections. Rifampin is an antitubercular agent, sulfamethoxazole and trimethoprim are used as a prophylaxis against Pneumocystis carinii pneumonia (PCP), and metronidazole is used to treat anaerobic and protozoic infections.

Rationale 3: A systemic antibiotic will be given for severe impetigo because it is a bacterial infection. Dicloxacillin is used in treatment of skin and soft-tissue infections. It is specific for treating staphylococcal infections. Rifampin is an antitubercular agent, sulfamethoxazole and trimethoprim are used as a prophylaxis against Pneumocystis carinii pneumonia (PCP), and metronidazole is used to treat anaerobic and protozoic infections.

Rationale 4: A systemic antibiotic will be given for severe impetigo because it is a bacterial infection. Dicloxacillin is used in treatment of skin and soft-tissue infections. It is specific for treating staphylococcal infections. Rifampin is an antitubercular agent, sulfamethoxazole and trimethoprim are used as a prophylaxis against Pneumocystis carinii pneumonia (PCP), and metronidazole is used to treat anaerobic and protozoic infections.

Global Rationale: A systemic antibiotic will be given for severe impetigo because it is a bacterial infection. Dicloxacillin is used in treatment of skin and soft-tissue infections. It is specific for treating staphylococcal infections. Rifampin is an antitubercular agent, sulfamethoxazole and trimethoprim are used as a prophylaxis against Pneumocystis carinii pneumonia (PCP), and metronidazole is used to treat anaerobic and protozoic infections.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 31.4 Plan the nursing care for the child with alterations in skin integrity, including dermatitis, infectious disorders, and infestations.

Question 7

Type: MCSA

An infant has a severe case of oral thrush (Candida albicans). Which nursing diagnosis is the priority for this infant?

1. Activity Intolerance Related to Oral Thrush

2. Ineffective Airway Clearance Related to Mucus

3. Ineffective Infant Feeding Pattern Related to Discomfort

4. Ineffective Breathing Pattern Related to Oral Thrush

Correct Answer: 3

Rationale 1: An infant with oral thrush may refuse to nurse or feed because of discomfort and pain. Prompt treatment is necessary so the infant can resume a normal feeding pattern. Activity intolerance, ineffective airway clearance, and ineffective breathing patterns are not usual associated problems.

Rationale 2: An infant with oral thrush may refuse to nurse or feed because of discomfort and pain. Prompt treatment is necessary so the infant can resume a normal feeding pattern. Activity intolerance, ineffective airway clearance, and ineffective breathing patterns are not usual associated problems.

Rationale 3: An infant with oral thrush may refuse to nurse or feed because of discomfort and pain. Prompt treatment is necessary so the infant can resume a normal feeding pattern. Activity intolerance, ineffective airway clearance, and ineffective breathing patterns are not usual associated problems.

Rationale 4: An infant with oral thrush may refuse to nurse or feed because of discomfort and pain. Prompt treatment is necessary so the infant can resume a normal feeding pattern. Activity intolerance, ineffective airway clearance, and ineffective breathing patterns are not usual associated problems.

Global Rationale: An infant with oral thrush may refuse to nurse or feed because of discomfort and pain. Prompt treatment is necessary so the infant can resume a normal feeding pattern. Activity intolerance, ineffective airway clearance, and ineffective breathing patterns are not usual associated problems.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 31.4 Plan the nursing care for the child with alterations in skin integrity, including dermatitis, infectious disorders, and infestations.

Question 8

Type: MCSA

The nurse is providing education to the parents of a pediatric client who is diagnosed with tinea capitis (ringworm of the scalp). Which statement made the parents indicates an appropriate understanding of the teaching session?

1. We will give the griseofulvin on an empty stomach.

2. Were glad ringworm isnt transmitted from person to person.

3. Once the lesion is gone, we can stop the griseofulvin.

4. We will give the griseofulvin with milk or peanut butter.

Correct Answer: 4

Rationale 1: Parents are advised to give oral griseofulvin with fatty foods such as milk or peanut butter to enhance absorption. The medication must be used for the entire prescribed period even if the lesions are gone. All members of the family and household pets should be assessed for fungal lesions because person-to-person transmission is common.

Rationale 2: Parents are advised to give oral griseofulvin with fatty foods such as milk or peanut butter to enhance absorption. The medication must be used for the entire prescribed period even if the lesions are gone. All members of the family and household pets should be assessed for fungal lesions because person-to-person transmission is common.

Rationale 3: Parents are advised to give oral griseofulvin with fatty foods such as milk or peanut butter to enhance absorption. The medication must be used for the entire prescribed period even if the lesions are gone. All members of the family and household pets should be assessed for fungal lesions because person-to-person transmission is common.

Rationale 4: Parents are advised to give oral griseofulvin with fatty foods such as milk or peanut butter to enhance absorption. The medication must be used for the entire prescribed period even if the lesions are gone. All members of the family and household pets should be assessed for fungal lesions because person-to-person transmission is common.

Global Rationale: Parents are advised to give oral griseofulvin with fatty foods such as milk or peanut butter to enhance absorption. The medication must be used for the entire prescribed period even if the lesions are gone. All members of the family and household pets should be assessed for fungal lesions because person-to-person transmission is common.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 31.4 Plan the nursing care for the child with alterations in skin integrity, including dermatitis, infectious disorders, and infestations.

Question 9

Type: MCSA

The school nurse is conducting pediculosis capitis (head lice) checks. Which findings would indicate a positive head check?

1. White, flaky particles throughout the entire scalp region

2. Maculopapular lesions behind the ears

3. Lesions in the scalp that extend to the hairline or neck

4. White sacs attached to the hair shafts in the occipital area

Correct Answer: 4

Rationale 1: Evidence of pediculosis capitis includes white sacs (nits) that are attached to the hair shafts, frequently in the occiput area. Lesions may be present from itching, but the positive sign is evidence of nits. Lice and nits must be distinguished from dandruff, which appears as white, flaky particles.

Rationale 2: Evidence of pediculosis capitis includes white sacs (nits) that are attached to the hair shafts, frequently in the occiput area. Lesions may be present from itching, but the positive sign is evidence of nits. Lice and nits must be distinguished from dandruff, which appears as white, flaky particles.

Rationale 3: Evidence of pediculosis capitis includes white sacs (nits) that are attached to the hair shafts, frequently in the occiput area. Lesions may be present from itching, but the positive sign is evidence of nits. Lice and nits must be distinguished from dandruff, which appears as white, flaky particles.

Rationale 4: Evidence of pediculosis capitis includes white sacs (nits) that are attached to the hair shafts, frequently in the occiput area. Lesions may be present from itching, but the positive sign is evidence of nits. Lice and nits must be distinguished from dandruff, which appears as white, flaky particles.

Global Rationale: Evidence of pediculosis capitis includes white sacs (nits) that are attached to the hair shafts, frequently in the occiput area. Lesions may be present from itching, but the positive sign is evidence of nits. Lice and nits must be distinguished from dandruff, which appears as white, flaky particles.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 31.1 Classify the characteristics of skin lesions caused by irritants, drug reactions, mites, infection, and injury.

Question 10

Type: MCSA

A nurse is caring for a toddler client who is diagnosed with scabies and prescribed a 5 percent permethrin lotion. How will the nurse apply this lotion when administering it to the toddler?

1. To the scalp only

2. Over the entire body from the chin down, as well as on the scalp and forehead

3. Only on the areas with evidence of scabies activity

4. Only on the hands

Correct Answer: 2

Rationale 1: Treatment of scabies involves application of a scabicide, such as 5 percent permethrin lotion, over the entire body from the chin down. The scabicide is also applied to the scalp and forehead of younger children, avoiding the rest of the face.

Rationale 2: Treatment of scabies involves application of a scabicide, such as 5 percent permethrin lotion, over the entire body from the chin down. The scabicide is also applied to the scalp and forehead of younger children, avoiding the rest of the face.

Rationale 3: Treatment of scabies involves application of a scabicide, such as 5 percent permethrin lotion, over the entire body from the chin down. The scabicide is also applied to the scalp and forehead of younger children, avoiding the rest of the face.

Rationale 4: Treatment of scabies involves application of a scabicide, such as 5 percent permethrin lotion, over the entire body from the chin down. The scabicide is also applied to the scalp and forehead of younger children, avoiding the rest of the face.

Global Rationale: Treatment of scabies involves application of a scabicide, such as 5 percent permethrin lotion, over the entire body from the chin down. The scabicide is also applied to the scalp and forehead of younger children, avoiding the rest of the face.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 31.4 Plan the nursing care for the child with alterations in skin integrity, including dermatitis, infectious disorders, and infestations.

Question 11

Type: SEQ

The nurse is caring for a pediatric client who sustained a severe burn. Determine the order of what would be done for this child when the medical team arrives on the scene:

Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list.

Response 1. Start intravenous fluids.

Response 2. Provide for relief of pain.

Response 3. Establish an airway.

Response 4. Place a Foley catheter.

Correct Answer: 3,1,2,4

Rationale 1: The first step in burn care is to ensure that the child has an airway, is breathing, and has a pulse. Due to the severity of the burn, establishing IV access and starting resuscitation fluids would be next, followed by addressing the area of pain and inserting a Foley catheter.

Rationale 2: The first step in burn care is to ensure that the child has an airway, is breathing, and has a pulse. Due to the severity of the burn, establishing IV access and starting resuscitation fluids would be next, followed by addressing the area of pain and inserting a Foley catheter.

Rationale 3: The first step in burn care is to ensure that the child has an airway, is breathing, and has a pulse. Due to the severity of the burn, establishing IV access and starting resuscitation fluids would be next, followed by addressing the area of pain and inserting a Foley catheter.

Rationale 4: The first step in burn care is to ensure that the child has an airway, is breathing, and has a pulse. Due to the severity of the burn, establishing IV access and starting resuscitation fluids would be next, followed by addressing the area of pain and inserting a Foley catheter.

Global Rationale: The first step in burn care is to ensure that the child has an airway, is breathing, and has a pulse. Due to the severity of the burn, establishing IV access and starting resuscitation fluids would be next, followed by addressing the area of pain and inserting a Foley catheter.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 31.7 Develop a nursing care plan for the child with a full-thickness burn injury.

Question 12

Type: MCSA

The nurse is providing care for a pediatric client who has a third-degree circumferential burn of the right arm. Which nursing diagnosis is the priority for this client?

1. Risk for Infection

2. Risk for Altered Tissue Perfusion

3. Risk for Altered Nutrition: Less than Body Requirements

4. Impaired Physical Mobility

Correct Answer: 2

Rationale 1: When the burn is circumferential, blood flow can become restricted due to edema and result in tissue hypoxia; therefore, the priority diagnosis is Risk for Altered Tissue Perfusion to the Extremity. Infection, Nutrition, and Mobility would have second priority in this case.

Rationale 2: When the burn is circumferential, blood flow can become restricted due to edema and result in tissue hypoxia; therefore, the priority diagnosis is Risk for Altered Tissue Perfusion to the Extremity. Infection, Nutrition, and Mobility would have second priority in this case.

Rationale 3: When the burn is circumferential, blood flow can become restricted due to edema and result in tissue hypoxia; therefore, the priority diagnosis is Risk for Altered Tissue Perfusion to the Extremity. Infection, Nutrition, and Mobility would have second priority in this case.

Rationale 4: When the burn is circumferential, blood flow can become restricted due to edema and result in tissue hypoxia; therefore, the priority diagnosis is Risk for Altered Tissue Perfusion to the Extremity. Infection, Nutrition, and Mobility would have second priority in this case.

Global Rationale: When the burn is circumferential, blood flow can become restricted due to edema and result in tissue hypoxia; therefore, the priority diagnosis is Risk for Altered Tissue Perfusion to the Extremity. Infection, Nutrition, and Mobility would have second priority in this case.

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 31.6 Summarize the process to measure the extent of burns and burn severity in children.

Question 13

Type: MCSA

During the recoverymanagement phase of burn treatment, which is the most common complication seen in children?

1. Shock

2. Metabolic acidosis

3. Burn-wound infection

4. Asphyxia

Correct Answer: 3

Rationale 1: Infection of the burned area is a frequent complication in the recoverymanagement phase. A goal of burn-wound care is protection from infection.

Rationale 2: Infection of the burned area is a frequent complication in the recoverymanagement phase. A goal of burn-wound care is protection from infection.

Rationale 3: Infection of the burned area is a frequent complication in the recoverymanagement phase. A goal of burn-wound care is protection from infection.

Rationale 4: Infection of the burned area is a frequent complication in the recoverymanagement phase. A goal of burn-wound care is protection from infection.

Global Rationale: Infection of the burned area is a frequent complication in the recoverymanagement phase. A goal of burn-wound care is protection from infection.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 31.7 Develop a nursing care plan for the child with a full-thickness burn injury.

Question 14

Type: MCSA

The nurse explains to the parents of a child with a severe burn that wearing of an elastic pressure garment (Jobst stocking) during the rehabilitative stage can help with the prevention of which complication?

1. Poor circulation

2. Hypertrophic scarring

3. Pain

4. Formation of thrombus in the burn area

Correct Answer: 2

Rationale 1: During the rehabilitation stage, Jobst stockings or pressure garments are used to reduce development of hypertrophic scarring and contractures.

Rationale 2: During the rehabilitation stage, Jobst stockings or pressure garments are used to reduce development of hypertrophic scarring and contractures.

Rationale 3: During the rehabilitation stage, Jobst stockings or pressure garments are used to reduce development of hypertrophic scarring and contractures.

Rationale 4: During the rehabilitation stage, Jobst stockings or pressure garments are used to reduce development of hypertrophic scarring and contractures.

Global Rationale: During the rehabilitation stage, Jobst stockings or pressure garments are used to reduce development of hypertrophic scarring and contractures.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 31.7 Develop a nursing care plan for the child with a full-thickness burn injury.

Question 15

Type: MCSA

A pediatric client sustains a minor burn. When teaching the family the treatment for this burn, the nurse would teach that the clients diet should be high in which substance?

1. Fats

2. Protein

3. Minerals

4. Carbohydrates

Correct Answer: 2

Rationale 1: Parents should be taught that management of a minor burn requires a high-calorie, high-protein diet. This is necessary to meet the increased nutritional requirements of healing.

Rationale 2: Parents should be taught that management of a minor burn requires a high-calorie, high-protein diet. This is necessary to meet the increased nutritional requirements of healing.

Rationale 3: Parents should be taught that management of a minor burn requires a high-calorie, high-protein diet. This is necessary to meet the increased nutritional requirements of healing.

Rationale 4: Parents should be taught that management of a minor burn requires a high-calorie, high-protein diet. This is necessary to meet the increased nutritional requirements of healing.

Global Rationale: Parents should be taught that management of a minor burn requires a high-calorie, high-protein diet. This is necessary to meet the increased nutritional requirements of healing.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 31.7 Develop a nursing care plan for the child with a full-thickness burn injury.

Question 16

Type: MCMA

The nurse is teaching a group of students about wound healing. Which items will the nurse include as occurring during the hemostasis and inflammation stage of wound healing?

Standard Text: Select all that apply.

1. Clot formation to seal the wound

2. Production of collagen and granulation tissue

3. Scar formation and strengthening

4. Release of inflammatory mediators by platelets

5. Swelling as a result of increased capillary permeability

Correct Answer: 1,2,5

Rationale 1: During the hemostasis and inflammation stage of wound healing, the nurse would state that clot formation occurs to seal the wound; platelets release inflammatory mediators; and increased capillary permeability results in swelling. Scar formation and strengthening occur during maturation. Collagen and granulation tissue are produced during tissue formation.

Rationale 2: During the hemostasis and inflammation stage of wound healing, the nurse would state that clot formation occurs to seal the wound; platelets release inflammatory mediators; and increased capillary permeability results in swelling. Scar formation and strengthening occur during maturation. Collagen and granulation tissue are produced during tissue formation.

Rationale 3: During the hemostasis and inflammation stage of wound healing, the nurse would state that clot formation occurs to seal the wound; platelets release inflammatory mediators; and increased capillary permeability results in swelling. Scar formation and strengthening occur during maturation. Collagen and granulation tissue are produced during tissue formation.

Rationale 4: During the hemostasis and inflammation stage of wound healing, the nurse would state that clot formation occurs to seal the wound; platelets release inflammatory mediators; and increased capillary permeability results in swelling. Scar formation and strengthening occur during maturation. Collagen and granulation tissue are produced during tissue formation.

Rationale 5: During the hemostasis and inflammation stage of wound healing, the nurse would state that clot formation occurs to seal the wound; platelets release inflammatory mediators; and increased capillary permeability results in swelling. Scar formation and strengthening occur during maturation. Collagen and granulation tissue are produced during tissue formation.

Global Rationale: During the hemostasis and inflammation stage of wound healing, the nurse would state that clot formation occurs to seal the wound; platelets release inflammatory mediators; and increased capillary permeability results in swelling. Scar formation and strengthening occur during maturation. Collagen and granulation tissue are produced during tissue formation.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 31.2 Differentiate among the stages of wound healing.

Question 17

Type: MCMA

The nurse is providing care to a pediatric client who is diagnosed with psoriasis. Which clinical manifestations does the nurse anticipate upon assessment of this client?

Standard Text: Select all that apply.

1. Thick, silvery, scaly erythematous plaque

2. Pruritus

3. Dry skin, likely to crack and fissure

4. Fragile skin and blisters

5. Irregular border surrounded by normal skin

Correct Answer: 1,2,5

Rationale 1: Clinical manifestations that support the diagnosis of psoriasis include thick, silvery, scaly erythematous plaque; pruritis; and irregular border surrounded by normal skin.  Dry skin that is likely to crack and fissure is a clinical manifestation of atopic dermatitis. Fragile skin and blisters are clinical manifestations of epidermolysis bullosa.

Rationale 2: Clinical manifestations that support the diagnosis of psoriasis include thick, silvery, scaly erythematous plaque; pruritis; and irregular border surrounded by normal skin.  Dry skin that is likely to crack and fissure is a clinical manifestation of atopic dermatitis. Fragile skin and blisters are clinical manifestations of epidermolysis bullosa.

Rationale 3: Clinical manifestations that support the diagnosis of psoriasis include thick, silvery, scaly erythematous plaque; pruritis; and irregular border surrounded by normal skin.  Dry skin that is likely to crack and fissure is a clinical manifestation of atopic dermatitis. Fragile skin and blisters are clinical manifestations of epidermolysis bullosa.

Rationale 4: Clinical manifestations that support the diagnosis of psoriasis include thick, silvery, scaly erythematous plaque; pruritis; and irregular border surrounded by normal skin.  Dry skin that is likely to crack and fissure is a clinical manifestation of atopic dermatitis. Fragile skin and blisters are clinical manifestations of epidermolysis bullosa.

Rationale 5: Clinical manifestations that support the diagnosis of psoriasis include thick, silvery, scaly erythematous plaque; pruritis; and irregular border surrounded by normal skin.  Dry skin that is likely to crack and fissure is a clinical manifestation of atopic dermatitis. Fragile skin and blisters are clinical manifestations of epidermolysis bullosa.

Global Rationale: Clinical manifestations that support the diagnosis of psoriasis include thick, silvery, scaly erythematous plaque; pruritis; and irregular border surrounded by normal skin.  Dry skin that is likely to crack and fissure is a clinical manifestation of atopic dermatitis. Fragile skin and blisters are clinical manifestations of epidermolysis bullosa.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 31.3 Compare skin conditions that have a hereditary cause or predisposition.

Question 18

Type: MCMA

The nurse is providing teaching to a community group regarding preventative strategies to reduce the risk of burn injury. Which topics will the nurse include in the teaching session?

Standard Text: Select all that apply.

1. Avoid contact with unknown animals and wild animals.

2. Layer childrens clothing for warmth.

3. Keep infants and toddlers off the lap when drinking hot beverages or eating soup.

4. Lower the temperature settings for hot water heaters.

5. Wear light-colored clothes and avoid eating sweetened foods and beverages when outside.

Correct Answer: 3,4

Rationale 1: In order to decrease the risk of burn injury, the nurse would tell the group to keep infants and toddlers off the lap while drinking hot beverages or eating soup and to lower the temperature settings for the hot water heaters.  Avoiding contact with unknown animals and wild animals along with wearing light-colored clothes and avoiding eating sweetened foods and beverages when outside are strategies to prevent bites and stings. Layering childrens clothing for warmth is a strategy to prevent hypothermia.

Rationale 2: In order to decrease the risk of burn injury, the nurse would tell the group to keep infants and toddlers off the lap while drinking hot beverages or eating soup and to lower the temperature settings for the hot water heaters.  Avoiding contact with unknown animals and wild animals along with wearing light-colored clothes and avoiding eating sweetened foods and beverages when outside are strategies to prevent bites and stings. Layering childrens clothing for warmth is a strategy to prevent hypothermia.

Rationale 3: In order to decrease the risk of burn injury, the nurse would tell the group to keep infants and toddlers off the lap while drinking hot beverages or eating soup and to lower the temperature settings for the hot water heaters.  Avoiding contact with unknown animals and wild animals along with wearing light-colored clothes and avoiding eating sweetened foods and beverages when outside are strategies to prevent bites and stings. Layering childrens clothing for warmth is a strategy to prevent hypothermia.

Rationale 4: In order to decrease the risk of burn injury, the nurse would tell the group to keep infants and toddlers off the lap while drinking hot beverages or eating soup and to lower the temperature settings for the hot water heaters.  Avoiding contact with unknown animals and wild animals along with wearing light-colored clothes and avoiding eating sweetened foods and beverages when outside are strategies to prevent bites and stings. Layering childrens clothing for warmth is a strategy to prevent hypothermia.

Rationale 5: In order to decrease the risk of burn injury, the nurse would tell the group to keep infants and toddlers off the lap while drinking hot beverages or eating soup and to lower the temperature settings for the hot water heaters.  Avoiding contact with unknown animals and wild animals along with wearing light-colored clothes and avoiding eating sweetened foods and beverages when outside are strategies to prevent bites and stings. Layering childrens clothing for warmth is a strategy to prevent hypothermia.

Global Rationale: In order to decrease the risk of burn injury, the nurse would tell the group to keep infants and toddlers off the lap while drinking hot beverages or eating soup and to lower the temperature settings for the hot water heaters.  Avoiding contact with unknown animals and wild animals along with wearing light-colored clothes and avoiding eating sweetened foods and beverages when outside are strategies to prevent bites and stings. Layering childrens clothing for warmth is a strategy to prevent hypothermia.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 31.8 Contrast preventive strategies to reduce the risk of injury from burns, hypothermia, bites, and stings.

Ball/Bindler/Cowen, Principles of Pediatric Nursing 6th Ed. Test Bank

Copyright 2015 by Pearson Education, Inc.

Leave a Reply