Midterm ch 31

Question 1

A 3-year-old child is brought to the emergency department after sustaining a burn from hot coffee. The nurse observes redness and blistering on the child’s hand. The child is crying and in pain. Which of the following is the priority nursing intervention for this child?

A. Administer pain relief as ordered

B. Apply a cold compress to the burn area

C. Cleanse the burn with soap and water

D. Assess for signs of shock

Answer 1

A. Administer pain relief as ordered

Rationale: Pain management is the priority in the immediate care of a child with a thermal burn. Once pain relief is administered, further assessment and care can be provided.

Question 2

A 5-year-old child presents to the clinic with second-degree burns on the hands after touching a hot stove. Which of the following is the most appropriate action for the nurse to take?

A. Apply a sterile dressing to the burn area and initiate an IV for fluid resuscitation

B. Cleanse the burn with soap and water, apply an ointment, and send the child home

C. Immerse the burn area in cool water and assess for signs of shock

D. Apply ice directly to the burn site to reduce swelling

Answer 2

C. Immerse the burn area in cool water and assess for signs of shock

Rationale: Immediate cooling with cool water is the first step in managing thermal burns to reduce pain and limit tissue damage. The nurse should also assess the child for signs of shock and ensure proper hydration.

Question 3

A nurse is educating the parents of a 2-year-old child on how to prevent thermal burns. Which of the following statements by the parents indicates a need for further teaching?

A. “We will ensure the child’s food is not too hot before serving.”

B. “We will use safety gates to keep the child away from the kitchen.”

C. “We will keep hot beverages out of the child’s reach, especially on the coffee table.”

D. “We will allow the child to play near a fireplace with supervision.”

Answer 3

D. “We will allow the child to play near a fireplace with supervision.”

Rationale: Children should never be allowed to play near a fireplace, even with supervision, due to the high risk of burns. Protective barriers should be used to prevent access to open flames.

Question 4

A 6-year-old child presents to the emergency department with burns on the arm after touching a high-voltage electrical wire. The nurse notes that the child is conscious but has a weak pulse and is experiencing difficulty breathing. What is the priority nursing action?

A. Apply cool compresses to the burn area

B. Initiate intravenous fluids for hydration

C. Perform a cardiovascular assessment and monitor vital signs

D. Assess the depth and extent of the burns

Answer 4

C. Perform a cardiovascular assessment and monitor vital signs

Rationale: Electrical burns can affect the heart, respiratory system, and other organs. Assessing the child’s cardiovascular status and monitoring for signs of electrical injury-related complications (e.g., arrhythmias, respiratory distress) is the priority.

Question 5

A child presents with first-degree burns after sun exposure. The nurse understands that which of the following is the most appropriate treatment for this type of burn?

A. Apply antibiotic ointment and cover with a sterile dressing

B. Administer pain medication and provide fluids for hydration

C. Gently cleanse the burn with soap and water, then apply aloe vera gel

D. Apply ice to the burn area to reduce pain and swelling

Answer 5

C. Gently cleanse the burn with soap and water, then apply aloe vera gel

Rationale: First-degree burns typically require gentle cleansing with mild soap and water and the application of soothing agents such as aloe vera gel. Ice should not be applied to burns, as it can cause further tissue damage.

Question 6

A 4-year-old child is diagnosed with a chemical burn after ingesting household cleaner. The nurse’s first action should be to:

A. Administer an antidote to counteract the poison
B. Flush the mouth and eyes with water if contamination is present
C. Place the child in a semi-Fowler’s position to ease breathing
D. Monitor vital signs and initiate IV fluids for hydration

Answer 6

B. Flush the mouth and eyes with water if contamination is present

Rationale: Immediate flushing of the area with water is essential in chemical burns to dilute and remove the caustic substance, minimizing further tissue damage. The child should then be assessed for airway compromise and systemic effects.

Question 7

A nurse is caring for a child with third-degree burns caused by exposure to a hot object. Which of the following is an expected clinical manifestation in this child?

A. Intense pain at the site of the burn
B. Blister formation at the burn site
C. Absence of pain due to nerve destruction
D. Skin redness and swelling

Answer 7

C. Absence of pain due to nerve destruction

Rationale: Third-degree burns destroy nerve endings, leading to a lack of pain sensation at the burn site. These burns also cause extensive tissue damage and require advanced medical intervention, such as grafting.

Question 8

A nurse is caring for a child who has sustained severe burns and is at risk for infection. Which of the following is the most important nursing intervention to prevent infection in this child?

A. Administer tetanus immunization as prescribed

B. Keep the burn area open to the air to promote healing

C. Administer antibiotics prophylactically as prescribed

D. Use aseptic technique when changing dressings or administering medications

Answer 8

D. Use aseptic technique when changing dressings or administering medications

Rationale: Aseptic technique is essential in preventing infection in burn patients. The skin is compromised, and bacteria can easily enter, so careful handling of dressings and medications is critical.

Question 9

A child presents with a sunburn that appears red and painful, with no blisters. The nurse recognizes this as a superficial partial-thickness burn. Which of the following characteristics is most consistent with this type of burn?

A. The burn extends into the dermis and causes scarring.
B. The skin is red, painful, and blanches with pressure.
C. Blisters are present at the site of the burn.
D. The skin is charred and has a leathery texture.

Answer 9

B. The skin is red, painful, and blanches with pressure.

Rationale: Superficial partial-thickness burns (first-degree burns) damage only the outer layer of the skin, causing erythema, pain, and blanching on pressure, without blister formation.

Question 10

A nurse is educating the parents of a child who has a superficial partial-thickness burn from a sunburn. Which of the following statements by the parents indicates that further teaching is needed?

A. “I will apply aloe vera to the burn to soothe the skin.”
B. “I will keep the area clean and apply an antibiotic ointment daily.”
C. “The skin will peel after a few days, and that is normal.”
D. “I will cover the burn with a thick layer of petroleum jelly to prevent infection.”

Answer 10

D. “I will cover the burn with a thick layer of petroleum jelly to prevent infection.”

Rationale: Petroleum jelly can retain heat and may cause further tissue damage. It is better to use a mild ointment or aloe vera and ensure proper cooling of the skin. Parents should avoid covering the burn with thick ointments or lotions that could trap heat.

Question 11

Which of the following is a characteristic of a superficial partial-thickness burn (first-degree burn)?

A. Skin appears red, and blisters form.
B. Skin is red and painful but does not have blisters.
C. The burn extends into the dermis and causes severe scarring.
D. The burn area is blackened, and there is no pain.

Answer 11

B. Skin is red and painful but does not have blisters.

Rationale: Superficial partial-thickness burns are limited to the epidermis and are characterized by redness, pain, and the absence of blisters. They typically heal in a few days.

Question 12

A 7-year-old child is admitted to the hospital with a superficial partial-thickness burn from touching a hot stove. The burn area is red, painful, and blanches with pressure. Which of the following is the priority nursing intervention?

A. Apply an ice pack to the burn to reduce swelling.
B. Administer pain medication as prescribed.
C. Cleanse the burn with soap and water, then apply a dressing.
D. Provide oral fluids to prevent dehydration.

Answer 12

B. Administer pain medication as prescribed.

Rationale: Pain management is the priority in the treatment of superficial partial-thickness burns. After providing pain relief, the nurse can proceed with other interventions such as cleansing and fluid management.

Question 13

A nurse is assessing a child with a superficial partial-thickness burn. Which of the following findings would indicate the burn is healing appropriately?

A. The burn area is dark brown and leathery.
B. The burn is red and painful with blister formation.
C. The skin begins to peel a few days after the burn.
D. The area remains erythematous and swollen for several weeks.

Answer 13

C. The skin begins to peel a few days after the burn.

Rationale: Superficial partial-thickness burns typically heal in a few days, and peeling occurs as the skin undergoes cell turnover. The absence of blister formation and the return of normal skin appearance indicate appropriate healing.

Question 14

A child presents with a burn that involves the epidermis and upper layers of the dermis. The burn site has blisters, erythema, and blanching with pressure, as well as pain and sensitivity to cold air. Which of the following is most characteristic of a partial-thickness (second-degree) burn?

A. Erythema and blister formation with pain and sensitivity.
B. No blister formation and severe scarring.
C. Full-thickness burn with nerve damage.
D. Charred tissue and no sensation in the affected area.

Answer 14

A. Erythema and blister formation with pain and sensitivity.

Rationale: Partial-thickness (second-degree) burns typically involve both the epidermis and upper layers of the dermis, leading to erythema, blisters, blanching on pressure, pain, and sensitivity to cold air. The burn heals in 10-14 days.

Question 15

A nurse is assessing a child with a partial-thickness burn. Which of the following findings would indicate that the burn is consistent with this classification?

A. The burn is deep and involves all layers of skin, including muscle and bone.

B. The area appears blackened, and there is no pain in the affected area.

C. The burn appears erythematous with no blister formation, and the child reports minimal discomfort.

D. The burn site is red with some blister formation, and the child is experiencing pain when exposed to cold air.

Answer 15

D. The burn site is red with some blister formation, and the child is experiencing pain when exposed to cold air.

Rationale: Partial-thickness burns involve the epidermis and upper dermis, resulting in erythema, blistering, pain, and sensitivity to cold air. The area typically heals within 10-14 days.

Question 16

A child with a partial-thickness (second-degree) burn is admitted to the hospital. Which of the following is a priority nursing intervention for this type of burn?

A. Administering a tetanus shot.
B. Providing wound care and pain management.
C. Applying a cold compress to the burn.
D. Administering antibiotics as the first line of treatment.

Answer 16

B. Providing wound care and pain management.

Rationale: The priority for partial-thickness burns is pain management and proper wound care to prevent infection and promote healing. A cold compress should be avoided to prevent further tissue damage, and antibiotics are not required unless there is evidence of infection.

Question 17

A nurse is educating the parents of a child who has a partial-thickness burn. Which of the following statements indicates the need for further teaching?

A. “The blisters may break open and should be kept clean to prevent infection.”

B. “The burn should heal in about 10-14 days with minimal scarring.”

C. “I should apply ice directly to the burn to reduce swelling.”

D. “The area may be painful for several days, and sensitivity to cold is common.”

Answer 17

C. “I should apply ice directly to the burn to reduce swelling.”

Rationale: Ice should not be applied directly to burns, as it may cause further tissue damage. Cooling the burn with tepid water is recommended. Ice can cause constriction of blood vessels, which may delay healing and worsen pain.

Question 18

A child with a partial-thickness burn is experiencing increased pain and sensitivity to cold air. Which of the following actions would be most appropriate to address the child’s discomfort?

A. Administer pain medication as ordered by the healthcare provider.
B. Apply an ice pack directly to the burned area.
C. Leave the burn open to air to speed up healing.
D. Cover the burn with a thick layer of petroleum jelly.

Answer 18

A. Administer pain medication as ordered by the healthcare provider.

Rationale: Pain management is a key aspect of treating partial-thickness burns. Administering prescribed pain medication will help reduce the child’s discomfort. Cold air sensitivity is a common symptom of partial-thickness burns due to nerve involvement.

Question 19

A nurse is assessing a child with a second-degree (partial-thickness) burn on the hand. The burn is painful, erythematous, and has blisters. Which of the following would indicate that the burn is healing appropriately?

A. The burn area becomes redder and more painful.

B. The blisters rupture and crust over, followed by peeling of the skin.

C. The burn area becomes increasingly swollen and discolored.

D. The burn heals without any scarring or pigmentation changes.

Answer 19

B. The blisters rupture and crust over, followed by peeling of the skin.

Rationale: In second-degree burns, blistering is common, and the burn typically heals with the blisters rupturing and crusting over. Skin peeling after a few days is normal as the new epidermal layer forms. Scarring is minimal but may occur depending on the severity of the burn.

Question 20

A child sustains a full-thickness (third-degree) burn. The burn appears brown and waxy, and the child reports no pain in the affected area. Which of the following is the most appropriate next action for the nurse to take?

A. Administer a pain assessment and oral analgesics.
B. Immediately cool the burn area with cold water.
C. Monitor for signs of hypovolemic shock and initiate fluid resuscitation.
D. Apply a topical antimicrobial ointment to the burn site.

Answer 20

C. Monitor for signs of hypovolemic shock and initiate fluid resuscitation.

Rationale: Full-thickness burns involve significant tissue damage, including nerve endings, and can cause fluid loss leading to hypovolemic shock. Fluid resuscitation is critical in the first 24 hours based on weight, burn surface area, and maintenance needs to prevent shock.

Question 21

A nurse is caring for a child with a third-degree (full-thickness) burn. Which of the following signs indicates the burn is healing properly?

A. The area remains firm, white, and waxy, with no visible changes in color.
B. The burn site appears sunken, and the child is experiencing no pain.
C. The skin around the burn turns dark brown and starts peeling off in large patches.
D. The burn becomes more painful, with erythema and blister formation.

Answer 21

B. The burn site appears sunken, and the child is experiencing no pain.

Rationale: Full-thickness burns typically cause tissue destruction down to the subcutaneous layer, which results in a sunken appearance. There is usually no pain due to nerve destruction. Healing often involves the use of skin grafts.

Question 22

Which of the following would be the most significant concern for a nurse when treating a child with a full-thickness burn?

A. Infection risk and prevention.
B. Pain management.
C. Maintaining nutritional needs.
D. Regaining full mobility of the affected area.

Answer 22

A. Infection risk and prevention.

Rationale: Infection is a critical concern in full-thickness burns due to the loss of the skin’s protective barrier. Ensuring strict infection control practices is vital in preventing sepsis and complications.

Question 23

A child with a full-thickness (third-degree) burn requires skin grafting. Which of the following is the primary goal of this intervention?

A. To reduce the need for pain medications.
B. To restore the protective barrier of the skin.
C. To increase mobility in the affected area.
D. To reduce the need for long-term fluid resuscitation.

Answer 23

B. To restore the protective barrier of the skin.

Rationale: Skin grafting is primarily performed to restore the skin’s protective barrier against infection, fluid loss, and further damage. It helps promote healing and reduce complications associated with the loss of skin integrity.

Question 24

A child is admitted with a full-thickness burn covering 30% of their total body surface area (TBSA). What is the most important consideration in the first 24 hours following the burn?

A. Fluid resuscitation to prevent hypovolemic shock.
B. Administering antibiotics to prevent infection.
C. Applying topical ointments to prevent scarring.
D. Initiating wound debridement and dressing changes.

Answer 24

A. Fluid resuscitation to prevent hypovolemic shock.

Rationale: In the first 24 hours, the primary concern is fluid resuscitation due to significant fluid loss from the burn injury. The child may experience hypovolemic shock, and adequate fluid replacement is necessary to maintain circulation and organ function.

Question 25

A child with a full-thickness (third-degree) burn exhibits sunken tissue and no pain in the affected area. Which of the following is most likely to occur in the recovery phase?

A. The tissue will heal by regeneration with no need for additional interventions.
B. The child will experience significant scarring and may require surgical intervention.
C. The burn site will develop increased erythema and blister formation.
D. The burn area will return to its original color without requiring grafting.

Answer 25

B. The child will experience significant scarring and may require surgical intervention.

Rationale: Full-thickness burns often result in significant scarring due to the depth of the injury, and the child will likely require surgical interventions, such as skin grafting, for functional and cosmetic restoration.

Question 26

A child with a full-thickness (third-degree) burn is being treated for fluid resuscitation. Which of the following would be the best indicator for the nurse to assess the effectiveness of the fluid therapy?

A. Increase in body temperature and pulse rate.
B. Reduction in the burn area size and less pain.
C. Skin grafting success and pain relief.
D. Improvement in urine output and normal blood pressure.

Answer 26

D. Improvement in urine output and normal blood pressure.

Rationale: Effective fluid resuscitation is primarily indicated by improving urine output (indicative of renal perfusion) and maintaining normal blood pressure, both of which help prevent hypovolemic shock. Monitoring these parameters is essential in burn management.

Question 27

A nurse is teaching the parents of a child with atopic dermatitis about managing flare-ups. Which of the following should be included in the teaching plan?

A. Use of frequent soap and hot water to cleanse the skin.

B. Use of scented lotions and bath products to soothe the skin.

C. Encouragement to allow the skin to dry out before moisturizing to prevent irritation.

D. Application of moisturizers immediately after bathing to lock in moisture.

Answer 27

D. Application of moisturizers immediately after bathing to lock in moisture.

Rationale: Atopic dermatitis benefits from moisturizing to maintain skin hydration. The skin should be moisturized immediately after bathing to lock in moisture and prevent dryness, which can exacerbate flare-ups.

Question 28

A 4-year-old child presents with redness, swelling, and itching around the diaper area. The nurse suspects diaper dermatitis. Which of the following interventions should the nurse recommend to the parents to prevent further irritation?

A. Frequent diaper changes and allowing the skin to air dry.

B. Use of alcohol-based wipes during diaper changes.

C. Applying petroleum jelly to the area to keep it moist.

D. Use of warm, soapy water to cleanse the area with each diaper change.

Answer 28

A. Frequent diaper changes and allowing the skin to air dry.

Rationale: Frequent diaper changes, ensuring the area is clean and dry, and allowing the skin to air dry help prevent diaper dermatitis. Moisture and friction contribute to irritation, so it’s important to minimize these factors.

Question 29

A nurse is assessing a 2-year-old with seborrheic dermatitis on the scalp. Which of the following characteristics would the nurse expect to observe?

A. Dry, flaky skin with a reddened appearance and no scaling.
B. Yellowish, greasy scales that form thick crusts on the scalp.
C. Blisters with fluid accumulation and significant pain.
D. Small, raised, itchy papules that are well-circumscribed.

Answer 29

B. Yellowish, greasy scales that form thick crusts on the scalp.

Rationale: Seborrheic dermatitis is characterized by yellowish, greasy scales that can form thick crusts, primarily on the scalp. It is a common condition in infants and often improves with age.

Question 30

A 6-year-old child has been diagnosed with contact dermatitis after coming into contact with poison ivy. Which of the following is the most appropriate intervention for the nurse to recommend for the child?

A. Apply a cold compress and hydrocortisone cream to the affected areas.
B. Encourage the child to scrub the affected areas with soap and water immediately.
C. Apply an antibiotic ointment to prevent infection.
D. Encourage wearing tight-fitting clothing to prevent scratching.

Answer 30

A. Apply a cold compress and hydrocortisone cream to the affected areas.

Rationale: Contact dermatitis from poison ivy can be treated with cold compresses and hydrocortisone cream to reduce inflammation and itching. Scrubbing the area could worsen irritation, and antibiotic ointments are not indicated unless there is evidence of infection.

Question 31

A nurse is educating the parents of a child with atopic dermatitis about avoiding triggers. Which of the following should be included in the teaching plan to minimize flare-ups?

A. Keep the child in synthetic fabrics to avoid wool irritation.
B. Encourage the child to bathe with hot water for cleansing.
C. Avoid excessive heat and sweating that can trigger flare-ups.
D. Ensure the child wears tight-fitting clothing to prevent scratching.

Answer 31

C. Avoid excessive heat and sweating that can trigger flare-ups.

Rationale: Excessive heat and sweating can exacerbate atopic dermatitis. Parents should be encouraged to keep the child cool and avoid sweating, which can irritate the skin and trigger flare-ups.

Question 32

A nurse is performing a skin assessment on a newborn and notices a rash with erythema and vesicular lesions in the diaper area. The nurse suspects diaper dermatitis. Which of the following is the most appropriate first-line treatment?

A. Use of a steroid cream to reduce inflammation.
B. Use of a topical antifungal cream.
C. Application of petroleum jelly to the affected areas.
D. Frequent diaper changes and application of a barrier cream.

Answer 32

D. Frequent diaper changes and application of a barrier cream.

Rationale: Frequent diaper changes to keep the area clean and dry, along with the application of a barrier cream (such as zinc oxide), is the first-line treatment for diaper dermatitis. This helps protect the skin from moisture and irritants.

Question 33

A nurse is assessing a child who was bitten by a dog. The nurse observes a crushing wound at the site of the bite, along with mild redness and swelling. Which of the following interventions should be included in the initial treatment of the bite?

A. Apply ice to reduce swelling and pain.
B. Administer a tetanus booster.
C. Irrigate the wound with povidone-iodine solution.
D. Immediately apply an antibiotic ointment to the wound

Answer 33

C. Irrigate the wound with povidone-iodine solution.

Rationale: The initial treatment of animal bites involves irrigation of the wound with a virucidal agent such as povidone-iodine solution to clean the wound, reduce the risk of infection, and remove any debris or devitalized tissue.

Question 34

A child presents with a puncture wound from a cat bite, and the wound is showing signs of erythema and swelling. Which of the following actions should the nurse prioritize in managing this injury?

A. Apply a topical antibiotic ointment and cover the wound with a sterile dressing.

B. Administer pain medication and allow the wound to heal on its own.

C. Prepare the child for debridement in the operating room if needed.

D. Observe the wound for 48 hours before taking any further action.

Answer 34

C. Prepare the child for debridement in the operating room if needed.

Rationale: Cat bites are often puncture wounds, and about 50% become infected. If the wound shows signs of infection, debridement may be required in the operating room to remove any infected or devitalized tissue, which can help prevent further complications.

Question 35

A child is brought to the emergency department with multiple puncture wounds from a dog bite. Which of the following is most important for the nurse to assess first?

A. Presence of cellulitis extending from the bite site.
B. Pain level and need for sedation.
C. Presence of foreign material in the wound.
D. Vital signs to assess for systemic infection.

Answer 35

A. Presence of cellulitis extending from the bite site.

Rationale: The nurse should assess for signs of cellulitis, such as redness extending from the bite site, which can indicate an infection. Identifying and managing infections early is crucial in preventing complications.

Question 36

A nurse is providing discharge teaching for the parent of a child who sustained a cat bite. The nurse explains the importance of seeking timely medical care. Why is delaying care for a cat bite particularly concerning?

A. Delayed care increases the risk of severe allergic reactions.

B. Delayed care increases the risk of systemic infection and complications.

C. Delayed care leads to scarring and cosmetic concerns.

D. Delayed care increases the risk of nerve damage at the site of the bite.

Answer 36

B. Delayed care increases the risk of systemic infection and complications.

Rationale: Delayed care after a cat bite increases the risk of infection and can lead to systemic complications, especially since cat bites tend to cause deep puncture wounds that are prone to infection.

Question 37

The nurse is preparing to administer prophylactic antibiotics to a child with a recent dog bite. Which of the following factors increases the need for prophylactic antibiotics in this case?

A. The bite occurred more than 12 hours ago.
B. The wound is a superficial scratch without puncture.
C. The bite was from a domestic dog that is up to date on vaccinations.
D. The child does not show signs of infection at this time.

Answer 37

A. The bite occurred more than 12 hours ago.

Rationale: Prophylactic antibiotics are particularly important when a bite occurs more than 12 hours ago or if there is any indication of infection, as the risk of bacterial infection increases with time, especially in puncture wounds.

Question 38

A nurse is assessing a child with a bite from a stray dog. The wound is large and deep, and the child is experiencing significant pain. Which of the following actions is most appropriate in the immediate management of this injury?

A. Clean the wound with soap and water, and apply a sterile dressing.

B. Give the child an over-the-counter analgesic and allow the wound to heal on its own.

C. Apply a topical antibiotic ointment and observe for signs of infection.

D. Irrigate the wound with povidone-iodine solution and provide pain management.

Answer 38

D. Irrigate the wound with povidone-iodine solution and provide pain management.

Rationale: Immediate wound irrigation with povidone-iodine solution to clean the wound and the administration of pain management are important steps in managing dog bites, especially if the bite is deep and causing significant pain.

Question 39

A nurse is reviewing a child’s chart who was recently treated for a cat bite. The nurse notes that the child is at high risk for infection due to the puncture nature of the wound. Which of the following should the nurse include in the care plan to prevent infection?

A. Administer a tetanus vaccine immediately after the bite.

B. Apply a warm compress to the affected area every 4 hours.

C. Instruct the family to clean the wound with hydrogen peroxide daily.

D. Ensure the child is given a full course of antibiotics to prevent infection.

Answer 39

D. Ensure the child is given a full course of antibiotics to prevent infection.

Rationale: Given the high risk of infection with puncture wounds from a cat bite, the child should be given a full course of antibiotics to reduce the risk of infection. Tetanus vaccination is not required for all cat bites, and hydrogen peroxide should be avoided as it can damage tissue.

Question 40

A nurse is assessing a child with cellulitis. Which of the following clinical manifestations would the nurse expect to observe in this child?

A. A well-defined, raised border around the affected area
B. Tender, warm, and edematous skin around the infected site
C. A localized rash that blanches with pressure
D. Clear, fluid-filled blisters at the site of infection

Answer 40

B. Tender, warm, and edematous skin around the infected site

Rationale: Cellulitis typically presents with tender, warm, and edematous skin, often with an indistinct border, indicating deep tissue infection. It does not present with a well-defined border or blisters.

Question 41

A 4-year-old child with cellulitis presents with fever, chills, and swollen lymph nodes. The nurse notices erythematous streaks extending in a proximal direction from the site of infection. This is indicative of which of the following?

A. Necrotizing fasciitis
B. Lymphangitis
C. Osteomyelitis
D. Periorbital cellulitis

Answer 41

B. Lymphangitis

Rationale: Lymphangitis, inflammation of the lymphatic system, is marked by tender, erythematous streaks extending from the infection site toward the proximal direction. It is a common finding in cellulitis.

Question 42

A child with cellulitis is being treated with IV antibiotics. The nurse educates the parents on the importance of follow-up care. Which of the following signs should prompt the parents to contact the healthcare provider immediately?

A. Increased appetite
B. Temperature of 37.5°C (99.5°F)
C. Spread of the infected area in the 24- to 48-hour period after starting treatment
D. Mild lethargy after activity

Answer 42

C. Spread of the infected area in the 24- to 48-hour period after starting treatment

Rationale: Parents should contact the healthcare provider if the infected area spreads after 24 to 48 hours of treatment, as this may indicate the infection is not responding to therapy or complications are occurring.

Question 43

Which of the following is the most likely causative organism for cellulitis in children?

A. Candida albicans
B. Staphylococcus aureus
C. Escherichia coli
D. Mycobacterium tuberculosis

Answer 43

B. Staphylococcus aureus

Rationale: Staphylococcus aureus, along with Streptococcus pyogenes, is the most common causative organism for cellulitis in children.

Question 44

A child with cellulitis is being treated with oral antibiotics at home. Which of the following instructions should the nurse emphasize to the parents?

A. “If the infection does not improve in 2 days, stop the antibiotics and call the doctor.”

B. “Do not apply warm compresses to the infected area.”

C. “After 5 days of treatment, you can discontinue the antibiotics if the fever resolves.”

D. “Be sure to elevate the affected limb to reduce swelling.”

Answer 44

D. “Be sure to elevate the affected limb to reduce swelling.”

Rationale: Elevating the affected limb helps reduce swelling, which is an important aspect of managing cellulitis. The full course of antibiotics should be completed even if the child begins to feel better.

Question 45

A child with cellulitis is receiving IV antibiotics and analgesics in the hospital. The nurse is assessing for complications. Which of the following complications should the nurse be most vigilant for in severe cellulitis cases?

A. Abscess formation
B. Sunburn
C. Hypertension
D. Sickle cell crisis

Answer 45

A. Abscess formation

Rationale: Abscess formation is a common complication of cellulitis, especially in severe cases, and should be monitored for closely.

Question 46

A 6-year-old child with cellulitis is experiencing rapid progression of the infection despite IV antibiotics. Blood cultures are positive for Streptococcus pyogenes. What is the priority action for the nurse?

A. Continue monitoring vital signs every 4 hours
B. Administer analgesics to relieve pain
C. Assess for signs of sepsis and prepare for more aggressive interventions
D. Apply warm compresses to the infected area

Answer 46

C. Assess for signs of sepsis and prepare for more aggressive interventions

Rationale: Rapid progression of cellulitis despite antibiotics and positive cultures for a virulent pathogen like Streptococcus pyogenes suggests possible sepsis. The nurse must assess for signs of systemic infection and prepare for more aggressive interventions.

Question 47

A nurse is caring for a child with cellulitis of the face. Which of the following interventions is most appropriate?

A. Administer oral antibiotics and send the child home after 24 hours of observation.

B. Hospitalize the child and initiate IV antibiotics to avoid complications such as necrotizing fasciitis.

C. Apply topical antibiotic ointment to the infected area and monitor for improvement.

D. Administer antipyretics to reduce fever, but no antibiotics are needed at this time.

Answer 47

B. Hospitalize the child and initiate IV antibiotics to avoid complications such as necrotizing fasciitis.

Rationale: Cellulitis of the face can be severe and may result in life-threatening complications, such as necrotizing fasciitis. IV antibiotics and hospitalization are necessary for close monitoring.

Question 48

A nurse is reviewing the lab results for a child with cellulitis. Which of the following findings would be most consistent with this condition?

A. Decreased white blood cell count
B. Low platelet count
C. High glucose level
D. Elevated white blood cell count

Answer 48

D. Elevated white blood cell count

Rationale: An elevated white blood cell count is a common finding in cellulitis, indicating an inflammatory or infectious process.

Question 49

A 3-year-old child with cellulitis is receiving IV antibiotics. The nurse is teaching the parents about the potential risks of cellulitis. Which of the following should be included in the education?

A. “Cellulitis can often be treated at home with over-the-counter medications.”

B. “Once the fever subsides, the infection is completely healed.”

C. “You should reduce fluid intake to minimize swelling.”

D. “If left untreated, cellulitis can lead to severe complications, such as sepsis or necrotizing fasciitis.”

Answer 49

D. “If left untreated, cellulitis can lead to severe complications, such as sepsis or necrotizing fasciitis.”

Rationale: Cellulitis, if left untreated, can lead to severe complications, including sepsis and necrotizing fasciitis. It is important to stress the potential seriousness of the infection.

Question 50

A nurse is caring for a child with cellulitis and is planning to administer oral antibiotics. Which of the following would be the most important for the nurse to assess prior to administering the antibiotics?

A. The child’s allergy history
B. The child’s current temperature
C. The child’s activity level
D. The child’s recent food intake

Answer 50

A. The child’s allergy history

Rationale: Prior to administering antibiotics, it is essential to assess the child’s allergy history to avoid any allergic reactions to the medication.

Question 51

A child with cellulitis is receiving treatment with IV antibiotics. Which of the following should the nurse include in the plan of care?

A. Limit fluid intake to prevent swelling.
B. Encourage the child to perform normal activities to avoid bed rest.
C. Use cold compresses to reduce inflammation at the site of infection.
D. Administer pain medications as prescribed.

Answer 51

D. Administer pain medications as prescribed.

Rationale: Pain management is an essential part of care for cellulitis, especially in severe cases. Elevating the limb and applying warm compresses (not cold) are more effective for reducing swelling and inflammation.