Chapter 49: The Child with an Alteration in Tissue Integrity My Nursing Test Banks

Chapter 49: The Child with an Alteration in Tissue Integrity

Test Bank

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 childs 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

Feedback

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 handwashing is imperative in preventing the spread of impetigo.

B

The lesions should be washed gently with a warm soapy washcloth three times a day. The washcloth should not be shared with other members of the family.

C

Itching is common and does not necessitate medical treatment. Rather, parents should be taught to clip the childs nails to prevent maceration of the lesions.

D

The child may return to school 24 hours after initiation of antibiotic treatment.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1306

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

2. When taking a history on a child with a possible diagnosis of cellulitis, what should be the priority nursing assessment to help establish a diagnosis?

a.

Any pain the child is experiencing

b.

Enlarged, mobile, and nontender lymph nodes

c.

Childs urinalysis results

d.

Recent infections or signs of infection

ANS: D

Feedback

A

Pain is important, but the history of recent infections is more relevant to the diagnosis.

B

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.

C

An abnormal urinalysis result is not usually associated with cellulitis.

D

Cellulitis may follow an upper respiratory infection, sinusitis, otitis media, or a tooth abscess. The affected area is red, hot, tender, and indurated.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1307

OBJ: Nursing Process: Assessment MSC: Client Needs: 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 sons 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 sons arm every 4 hours.

ANS: D

Feedback

A

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.

B

A warm soak is indicated for the treatment of cellulitis. Ice will decrease circulation to the affected area and inhibit the healing process.

C

The disappearance of redness indicates healing and is not a reason to seek medical advice.

D

Warm soaks applied every 4 hours while the child is awake increase circulation to the infected area, relieve pain, and promote healing.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1307

OBJ: Nursing Process: Evaluation MSC: Client Needs: 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 before the infant is fed.

d.

Swab nystatin suspension onto the oral mucous membranes after feedings.

ANS: D

Feedback

A

Medication may not reach the affected areas when it is squirted into the infants mouth. Rubbing the suspension onto the gum ensures contact with the affected areas.

B

Nystatin cream is used for diaper rash caused by Candida.

C

To prolong contact with the affected areas, the medication should be administered after a feeding.

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.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1308

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

5. With what beverage should the parents of a child with ringworm be taught to give griseofulvin?

a.

Water

b.

A carbonated drink

c.

Milk

d.

Fruit juice

ANS: C

Feedback

A

Griseofulvin is insoluble in water.

B

Carbonated drinks do not contain fat, which aids in the absorption of griseofulvin.

C

Griseofulvin is insoluble in water. Giving the medication with a high-fat meal or milk increases absorption.

D

Fruit juice does not contain any fat; fat aids absorption of the medication.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1310

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

6. Which nursing 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

Feedback

A

An oral herpetic infection does not affect joint function.

B

The child with herpetic gingivostomatitis is at risk for deficient fluid volume. Painful lesions on the mouth make drinking unpleasant and undesirable, with subsequent dehydration becoming a real danger.

C

Herpetic gingivostomatitis is not a chronic disorder that would affect the childs long-term growth pattern.

D

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.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 1313

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

7. Parents of a 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

Feedback

A

Antilice products are not known to be nephrotoxic.

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.

C

Antilice products are not ototoxic.

D

Products that treat lice are not known to cause bone marrow depression.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1315

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

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

a.

Asthma

b.

Nephrosis

c.

Lower respiratory tract infections

d.

Neurotoxicity

ANS: A

Feedback

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.

B

Complications of atopic dermatitis relate to the skin. The renal system is not affected by atopic dermatitis.

C

There is no link between lower respiratory tract infections and atopic dermatitis.

D

Atopic dermatitis does not have a relationship to neurotoxicity.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1302

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

9. What should the nurse teach an adolescent who is taking tretinoin (Retin-A) to treat 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

Feedback

A

Tretinoin is a topical medication. Application is not affected by meals.

B

Tretinoin causes photosensitivity, and sunscreen should be applied before sun exposure.

C

If applied together, benzoyl peroxide and tretinoin have reduced effectiveness and a potentially irritant effect.

D

Optimal results from tretinoin are not achieved for 3 to 5 months.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1318

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

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

a.

Primary candidiasis

b.

Irritant contact dermatitis

c.

Intertrigo

d.

Seborrheic dermatitis

ANS: A

Feedback

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.

B

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.

C

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.

D

Seborrheic dermatitis is recognized by salmon-colored, greasy lesions with a yellowish scale found primarily in skin-fold areas or on the scalp.

PTS: 1 DIF: Cognitive Level: Application REF: pp. 1308-1309

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

Feedback

A

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)?

B

The vocabulary to classify the depth of a burn is superficial, partial thickness, or full thickness.

C

These terms refer to the cause of the burn injury.

D

These terms refer to the severity of the burn injury.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1325 | Table 49-4

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

12. What 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

Feedback

A

Erythema and pain are characteristic of a first-degree burn or superficial burn.

B

Erythema with blister formation is characteristic of a second-degree or partial-thickness burn.

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.

D

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: p. 1325 | Table 49-4

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

13. What 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

Feedback

A

Cleaning with mild soap and water are important to the healing process.

B

Antimicrobial ointment is used on the burn wound to fight infection.

C

Clean dressings are applied daily to prevent wound infection. When dressings are changed, the condition of the burn wound can be assessed.

D

All loose skin and tissue should be debrided, because it can become a breeding ground for infectious organisms.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1329

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

14. The process of burn shock continues until what physiologic 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

Feedback

A

The heart rate will be increased throughout the healing process because of increased metabolism.

B

Airway swelling subsides over a period of 2 to 5 days after injury.

C

Body temperature regulation will not be normal until healing is well under way.

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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1331

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

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

a.

Distal pulses

b.

Skin turgor

c.

Urine output

d.

Mucous membranes

ANS: C

Feedback

A

Distal pulses may be affected by many variables. Urine output is the most reliable indicator of end-organ perfusion.

B

Skin turgor is often difficult to assess on burn patients because the skin is not intact.

C

Urine output reflects the adequacy of end-organ perfusion.

D

Mucous membranes do not reflect end-organ perfusion.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 1331

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

16. What 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 childs airway

b.

Establishing and maintaining intravenous access

c.

Inserting a catheter to monitor hourly urine output

d.

Inserting a nasogastric tube into the stomach to supply adequate nutrition

ANS: A

Feedback

A

Establishing and maintaining the childs airway is always the priority focus for assessment and care.

B

Establishing intravenous access is the second priority in this situation, after the airway has been established.

C

Inserting a catheter and monitoring hourly urine output is the third most important nursing intervention.

D

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: p. 1331

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

17. An important nursing consideration when caring for a child with impetigo contagiosa is to

a.

Apply topical corticosteroids to decrease inflammation.

b.

Carefully remove dressings so as not to dislodge undermined skin, crusts, and debris.

c.

Carefully wash hands and maintain cleanliness when caring for an infected child.

d.

Examine child under a Wood lamp for possible spread of lesions.

ANS: C

Feedback

A

Corticosteroids are not indicated in bacterial infections.

B

Dressings are usually not indicated. The undermined skin, crusts, and debris are carefully removed after softening with moist compresses.

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 handwashing before and after contact with the affected child.

D

A Wood 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: p. 1306

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

18. Impetigo ordinarily results in

a.

No scarring

b.

Pigmented spots

c.

Slightly depressed scars

d.

Atrophic white scars

ANS: A

Feedback

A

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

B

Hyperpigmentation may occur; however, only in dark skinned children.

C

No scarring usually occurs.

D

No scarring usually occurs.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1305

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

19. The pediatric nurse understands that cellulitis is most often caused by

a.

Herpes zoster

b.

Candida albicans

c.

Human papillomavirus

d.

Streptococcus or Staphylococcus organisms

ANS: D

Feedback

A

Herpes zoster is the virus associated with varicella and shingles.

B

Candida albicans is associated with candidiasis or thrush.

C

Human papillomavirus is associated with various types of human warts.

D

Streptococcus, Staphylococcus, and Haemophilus influenzae are the organisms usually responsible for cellulitis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1307

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

20. The skin condition commonly known as warts is the result of an infection by which organism?

a.

Bacteria

b.

Fungus

c.

Parasite

d.

Virus

ANS: D

Feedback

A

Infection with these organisms does not result in warts.

B

Infection with these organisms does not result in warts.

C

Infection with these organisms does not result in warts.

D

Human warts are caused by the human papillomavirus.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1320 | Table 49-1

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

21. The primary treatment for warts is

a.

Vaccination

b.

Local destruction

c.

Corticosteroids

d.

Specific antibiotic therapy

ANS: B

Feedback

A

Vaccination is prophylaxis for warts and is not a treatment.

B

Topical treatments include chemical cautery, which is especially useful for the treatment of warts. Local destructive therapy individualized according to location, type, and number. Surgical removal, electrocautery, curettage, cryotherapy, caustic solutions, x-ray treatment, and laser therapies are used.

C

These are not effective in the treatment of warts.

D

These are not effective in the treatment of warts.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1320 | Table 49-1

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

22. Treatment for herpes simplex virus (types 1 or 2) includes

a.

Corticosteroids

b.

Oral griseofulvin

c.

Oral antiviral agent

d.

Topical and/or systemic antibiotic

ANS: C

Feedback

A

Corticosteroids are not effective for viral infections.

B

Griseofulvin is an antifungal agent and not effective for viral infections.

C

Oral antiviral agents are effective for viral infections such as herpes simplex.

D

Antibiotics are not effective in viral diseases.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1313

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

23. Ringworm, frequently found in schoolchildren, is caused by a(n)

a.

Virus

b.

Fungus

c.

Allergic reaction

d.

Bacterial infection

ANS: B

Feedback

A

These are not the causative organisms for ringworm.

B

Ringworm is caused by a group of closely related filamentous fungi, which invade primarily the stratum corneum, hair, and nails. They are superficial infections that live on, not in, the skin.

C

Ringworm is not an allergic response.

D

These are not the causative organisms for ringworm.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1310

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

24. The primary clinical manifestation of scabies is

a.

Edema

b.

Redness

c.

Pruritus

d.

Maceration

ANS: C

Feedback

A

Edema is not observed in scabies.

B

Redness is not observed in scabies.

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.

D

Maceration is not observed in scabies.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1316

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

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

a.

Cool compresses

b.

Warm compresses

c.

Antibiotic cream

d.

Corticosteroid cream

ANS: A

Feedback

A

Bee or wasp stings are initially treated by carefully removing the stinger, cleansing with soap and water, application of cool compresses, and the use of common household agents such as lemon juice or a paste made with aspirin and baking soda.

B

Warm compresses are avoided.

C

Antibiotic cream is unnecessary unless a secondary infection occurs.

D

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: p. 1321 | Table 49-2

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

26. 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 stinger.

c.

Take child to emergency department.

d.

Apply a thin layer of corticosteroid cream.

ANS: C

Feedback

A

Warm compresses increase the circulation to the area and facilitate the spread of the venom.

B

The black widow spider does not have a stinger.

C

The black widow spider has a venom that is toxic enough to be harmful. The father should take the child to the emergency department for immediate treatment.

D

Corticosteroid cream will have no effect on the venom.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1322 | Table 49-2

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

27. 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 child quiet and come to emergency department

d.

Removing stinger and apply cool compresses

ANS: C

Feedback

A

Antihistamines are not effective against scorpion venom.

B

The wound will have intense local pain. Emergency treatment is indicated.

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.

D

The wound will have intense local pain. Emergency treatment is indicated.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 1322 | Table 49-2

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

28. Rocky Mountain spotted fever is caused by the bite of a

a.

Flea

b.

Tick

c.

Mosquito

d.

Mouse or rat

ANS: B

Feedback

A

These organisms do not transmit Rocky Mountain spotted fever.

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.

C

These organisms do not transmit Rocky Mountain spotted fever.

D

These organisms do not transmit Rocky Mountain spotted fever.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1322 | Table 49-2

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

29. A child experiences frostbite of the fingers after prolonged exposure to the cold. Which intervention should 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

Feedback

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).

B

The frostbitten area should be rewarmed as soon as possible to avoid further tissue damage.

C

Rapid rewarming results in less tissue necrosis than slow thawing.

D

The frostbitten area should be rewarmed, as soon as possible, to avoid further tissue damage.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 1320 | Table 49-1

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

MULTIPLE RESPONSE

1. 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

ANS: A, C, E

Feedback

Correct

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.

Incorrect

These lesions are not typically on the back or the buttocks.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1302

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

2. 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

Feedback

Correct

Prompt, gentle cleaning with water and mild soap (e.g., 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 (e.g., 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.

Incorrect

Occlusion increases the risk of systemic absorption of a 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. A steroid cream is not recommended.

PTS: 1 DIF: Cognitive Level: Application REF: pp. 1301-1302

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

3. 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

Feedback

Correct

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 crme rinse is applied to the hair after it is washed with a conditioner-free shampoo. The product should be rinsed out after 10 minutes.

Incorrect

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.

PTS: 1 DIF: Cognitive Level: Application REF: pp. 1315-1316

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

COMPLETION

1. A new mother calls the pediatricians office concerned because her newborn has developed a salmon colored, irregularly shaped spot between the eyes. The lesion becomes darker when the baby is crying. This skin lesion is called a(n) ____________.

ANS:

salmon patch

The nurse can reassure the mother that salmon patches are commonly known as stork bites or angel kisses. These lesions are benign and usually fade during the first year of life. The only treatment necessary is parental education.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1298

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

TRUE/FALSE

1. Electric injury to a child often results in instant death because the electric current disrupts the rhythm of the heart. Is this statement true or false?

ANS: T

The child who does not die instantly after an electrical injury is at risk for cardiac arrest or dysrhythmia, tissue damage, myoglobinuria, and metabolic acidosis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1331

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

Leave a Reply