Nokea
The nurse identifies the concept of impaired skin integrity for a pediatric client diagnosed with impetigo on the arms. Which interventions should the nurse implement?
- A. Teach the parents to ensure the child takes all the prescribed antibiotics.
- B. Give the parents a written excuse so the child can go back to school.
- C. Encourage the parents to bathe the child in an oatmeal bath for the itching.
- D. Apply topical lidocaine before debriding the crusts from the lesions.
Correct Answer: A
Rationale: Completing antibiotics ensures impetigo resolution, addressing skin integrity. School return requires clearance, oatmeal baths are for comfort, and lidocaine is unnecessary.
You may also like to solve these questions
The nurse correctly teaches the client that psoriasis is an inflammatory dermatosis that results from which skin condition?
- A. A superficial skin infection
- B. The effects of dermal abrasion
- C. A proliferation of epidermal cells
- D. An infection of the hair follicles
Correct Answer: C
Rationale: Psoriasis involves rapid epidermal cell turnover.
Which response demonstrates that the parents understand the nurse's explanation of why organisms travel more easily from the nasopharynx to the middle ear in a child?
- A. A child's eustachian tube is shorter and straighter.
- B. A child's eustachian tube is longer and straighter.
- C. A child's eustachian tube is longer and more curved.
Correct Answer: A
Rationale: A shorter, straighter eustachian tube in children facilitates organism travel.
The nurse determines that the fluid status of the client with a second-degree burn is inadequate and immediately notifies the HCP. The client is 5 hours postburn and weighs 60 kg. Which findings prompted the nurse's action?
- A. Blood pressure 92/60 mm Hg and pulse 100 bpm
- B. Respirations 18 per minute and pulse 60 bpm
- C. Pulse 130 bpm and urine output 25 mL/hr
- D. Pulse 106 bpm and temperature 98.4°F (36.9°C)
Correct Answer: C
Rationale: The client weighing 60 kg weighs 132 lb (1 kg = 2.2 lb). For the adult client weighing 132 lb, a pulse rate of 130 bpm (tachycardia) and a low urine output of 25 mL/hr are signs of inadequate circulating fluid volume. The MAP for a BP of 92/60 mm Hg is 70.7, indicating adequate perfusion. A pulse of 100 bpm is WNL. Respirations of 18 per minute and pulse of 60 bpm are both WNL. A pulse of 106 bpm could be elevated due to pain, and the temperature of 98.4°F (36.9°C) is considered normal.
Which questions should the nurse ask to investigate the cause of the client's rash? Select all that apply.
- A. Have you eaten foods that are different from your normal diet?
- B. Have you taken any new medications?
- C. Have you changed your laundry detergent?
- D. Have you been exposed to excessive sunlight?
- E. Have you been exercising in a gym?
- F. Have you gotten any new pets?
Correct Answer: A,B,C,D,F
Rationale: These factors are common triggers for rashes.
The client is complaining of severe itching following a course of antibiotics. Which independent nursing action should the nurse implement?
- A. Refer to an allergy specialist to begin desensitization.
- B. Use a tar-preparation gel after each shower or bath.
- C. Keep the covers tightly around the client at night.
- D. Take baths with an OTC colloidal oatmeal preparation.
Correct Answer: D
Rationale: Colloidal oatmeal baths relieve itching, an independent nursing action. Specialist referral, tar gels, and tight covers are inappropriate or dependent.