chapter 16 Flashcards
- Deficiency of which vitamin or mineral results in an inadequate inflammatory response?
a. A
b. B1
c. C
d. Zinc
ANS: A. A
A deficiency of vitamin A results in an inadequate inflammatory response. Deficiencies of vitamins B1 and C
result in decreased collagen formation. A deficiency of zinc leads to impaired epithelialization.
- Deficiency of which vitamin or mineral results in an inadequate inflammatory response?
a. A
b. B1
c. C
d. Zinc
ANS: A. A
A deficiency of vitamin A results in an inadequate inflammatory response. Deficiencies of vitamins B1 and C
result in decreased collagen formation. A deficiency of zinc leads to impaired epithelialization.
- An occlusive dressing is applied to a large abrasion. This is advantageous because the dressing will
accomplish what?
a. Deliver vitamin C to the wound.
b. Provide an antiseptic for the wound.
c. Maintain a moist environment for healing.
d. Promote mechanical friction for healing
ANS: C Maintain a moist environment for healing
Occlusive dressings, such as Acuderm, are not adherent to the wound site. They provide a moist wound surface
and insulate the wound. The dressing does not have vitamin C or antiseptic capabilities. Acuderm protects
against friction.
- A toddler has a deep laceration contaminated with dirt and sand. Before closing the wound, the nurse should
irrigate with what solution?
a. Alcohol
b. Normal saline
c. Povidoneiodine
d. Hydrogen peroxide
ANS: B Normal saline
Normal saline is the only acceptable fluid for irrigation listed. The nurse should cleanse the wound with a
forced stream of normal saline or water. Alcohol is not used for wound irrigation. Povidoneiodine is
contraindicated for cleansing fresh, open wounds. Hydrogen peroxide can cause formation of subcutaneous gas
when applied under pressure.
- The nurse should know what about Lyme disease?
a. Very 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 Caused by a spirochete that enters the skin through a tick bite
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
worn. Early treatment of the erythema migrans (stage 1) can prevent the development of Lyme disease. Lyme
disease is caused by a spirochete, not mycotic spores.
- The school nurse is seeing a child who collected some poison ivy leaves during recess. He says only his hands touched it. What is the most appropriate nursing action?
a. Soak his hands in warm water.
b. Apply Burows solution compresses.
c. Rinse his hands in cold running water.
d. Scrub his hands thoroughly with antibacterial soap.
ANS : C Rinse his hands in cold running water.
The first recommended action is to rinse his hands in cold running water within 15 minutes of exposure. This
will neutralize the urushiol not yet bonded to the skin. Soaking his hands in warm water is effective for
soothing the skin lesions after the dermatitis has begun. Antibacterial soap removes protective skin oils and
dilutes the urushiol, allowing it to spread.
- A 6-year-old boy with very fair skin will be joining his family during a beach vacation. What should the
nurse recommend?
a. Keep him off the beach during the daytime hours.
b. Use sunscreen with an SPF of at least 15 and reapply it every 2 to 3 hours.
c. Apply a topical sunscreen product with an SPF of 30 in the morning.
d. Dress him in long pants and long-sleeved shirt and keep him under a beach umbrella.
ANS: B Use sunscreen with an SPF of at least 15 and reapply it every 2 to 3 hours.
A sunscreen with an SPF (sun protection factor) of at least 15 is recommended. The sunscreen should be
reapplied every 2 to 3 hours and after the child is in the water or sweating excessively. During a beach
vacation, avoiding the beach during daytime hours is impractical. The highest risk of sun exposure is from 10
AM to 3 PM. Sunlight exposure should be limited during this time. An SPF of 30 is good, but reapplying it is
necessary every 2 to 3 hours and when the child gets wet. Long pants and a shirt are impractical. The beach
umbrella can be used with the sunscreen to limit exposure to the sun.
- The management of a child who has just been stung by a bee or wasp should include applying what?
a. Cool compresses
b. Antibiotic cream
c. Warm compresses
d. Corticosteroid cream
ANS: A Cool compresses
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. Antibiotic cream is unnecessary unless a secondary infection occurs. Warm
compresses are avoided. Corticosteroid cream is not part of the initial therapy. If a severe reaction occurs, systemic corticosteroids may be indicated.
- A parent calls the clinic nurse because his 7-year-old child was bitten by a black widow spider. What action
should the nurse advise the parent to take?
a. Apply warm compresses.
b. Carefully scrape off the stinger.
c. Take the child to the emergency department.
d. Apply a thin layer of corticosteroid cream.
ANS: C Take the child to the emergency department
The venom of the black widow spider has a neurotoxic effect. The parent should take the child to the
emergency department for treatment with antivenin and muscle relaxants as needed. 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 the venom.
- A school-age child has been bitten on the leg by a large snake that may be poisonous. During transport to an
emergency facility, what should the care include?
a. Apply ice to the snakebite.
b. Immobilize the leg with a splint.
c. Place a loose tourniquet distal to the bite.
d. Apply warm compresses to the snakebite
ANS: B Immobilize the leg with a splint.
The leg should be immobilized. Ice decreases blood flow to the area, which allows the venom to work more
destruction and decreases the effect of antivenin on the natural immune mechanisms. A loose tourniquet is
placed proximal, not distal, to the area of the bite to delay the flow of lymph. This can delay movement of the
venom into the peripheral circulation. The tourniquet should be applied so that a pulse can be felt distal to the
bite. Warmth increases circulation to the area and helps the toxin into the peripheral circulation.
- Parents phone the nurse and say that their child just knocked out a permanent tooth. What should the nurses instructions to the parents include?
a. Place the tooth in dry container for transport.
b. Hold the tooth by the crown and not by the root area.
c. Transport the child and tooth to a dentist within 18 hours.
d. Take the child to hospital emergency department if his or her mouth is bleeding
ANS: B Hold the tooth by the crown and not by the root area.
It is important to avoid touching the root area of the tooth. The tooth should be held by the crown area; rinsed
in milk, saline, or running water; and reimplanted as soon as possible. The tooth is kept moist during transport
to maintain viability. Cold milk is the most desirable medium for transport. The child needs to be seen by a
dentist as soon as possible. Tooth evulsion causes a large amount of bleeding. The child will need to be seen by
a dentist because of the loss of a tooth, not the bleeding.
- Parents are concerned that their 6-year-old son continues to occasionally wet the bed. What does the nurse
explain?
a. This is likely because of increased stress at home.
b. Enuresis usually ceases between 6 and 8 years of age.
c. Drug therapy will be prescribed to treat the enuresis.
d. Testing will be necessary to determine what type of kidney problem exists.
ANS: B Enuresis usually ceases between 6 and 8 years of age.
Further data must be gathered before the diagnosis of enuresis is made. Enuresis is the inappropriate voiding of
urine at least twice a week. This child does meet the age criterion, but the parents need to be questioned about
and keep a diary on the frequency of events. If the bedwetting is infrequent, parents can be encouraged that the
child may grow out of this behavior. Drug therapy will not be prescribed until a more complete evaluation is
done. Additional assessment information must be gathered, but at this time, there is no indication of renal
disease.
- The nurse is assisting the family of a child with a history of encopresis. What should be included in the
nurses discussion with the family?
a. Instruct the parents to sit the child on the toilet at twice-daily routine intervals.
b. Instruct the parents that the child will probably need to have daily enemas.
c. Suggest the use of stimulant cathartics weekly.
d. Reassure the family that most problems are resolved successfully, with some relapses during periods of stress.
ANS: D Reassure the family that most problems are resolved successfully, with some relapses during periods of stress.
Children may be unaware of a prior sensation and be unable to control the urge after it begins. They may be so
accustomed to bowel accidents that they may be unable to smell or feel them. Family counseling is directed
toward reassurance that most problems resolve successfully, although relapses during periods of stress are
possible. Sitting the child on the toilet is not recommended because it may intensify the parentchild conflict. Enemas may be needed for impactions, but long-term use prevents the child from assuming responsibility for
defecation. Stimulant cathartics may cause cramping that can frighten children.
- What is an important consideration in the diagnosis of attention deficit hyperactivity disorder (ADHD)?
a. Learning disabilities are apparent at an early age.
b. The child will always be distracted by external stimuli.
c. Parental observations of the childs behavior are most relevant.
d. It must be determined whether the childs behavior is age appropriate or problematic.
ANS: D It must be determined whether the childs behavior is age appropriate or problematic.
The diagnosis of ADHD is complex. A multidisciplinary evaluation should be done to determine whether the
childs behavior is appropriate for the developmental age or whether it is problematic. Learning disabilities are
usually not evident until the child enters school. Each child with ADHD responds differently to stimuli. Some
children are distracted by internal stimuli and others by external stimuli. Parents can only provide one
viewpoint of the childs behavior. Many observers should be asked to provide input with structured tools to
facilitate the diagnosis.
- The nurse is facilitating a conference between the teachers and parents of a 7-year-old child newly diagnosed with attention deficit hyperactivity disorder (ADHD). What does the nurse stress?
a. Academic subjects should be taught in the afternoon.
b. Low-interest activities in the classroom should be minimized.
c. Visual references should accompany verbal instruction.
d. The childs environment should be visually stimulating.
ANS: C Visual references should accompany verbal instruction.
Verbal instructions should always be accompanied by visual or written instructions. This provides the child
with reinforcement and a reference to expectations. Academic subjects should be taught in the morning when
the child is experiencing the effects of the morning dose of medication. Low-interest activities should be mixed
with high-interest activities to maintain the childs attention. Environmental stimulation should be minimized to
help eliminate distractions that can overexcite the child.
