NCLEX Pediatric: Integumentary Questions
Pediatric: Integumentary NCLEX Practice Questions
Question 1.
The nurse in the pediatric emergency room is caring for a toddler who sustained burns on the upper torso from a house fire. Which of the following nursing diagnoses is highest priority for this child?
(a) Potential ineffective airway clearance related to edema of respiratory passages
(b) Impaired physical mobility related to disease process
(c) Disturbed sleep pattern related to facility environment
(d) Risk for infection related to impaired skin integrity
Answer:
(a) Potential ineffective airway clearance related to edema of respiratory passages
Explanation:
Any time a child sustains burns to the upper torso, upper extremities, face, head, or neck, the primary goal of the nurse is to maintain integrity of the respiratory system. Airway clearance and reducing or preventing edema of respiratory passages are highest priorities in this scenario.
Rationale:
(a) is incorrect because burns are not a disease, and physical mobility is not as concerning as airway clearance and effective air exchange.
(c) is incorrect because the patient is likely to have a disturbed sleep pattern which can impact healing, but this is not a greater priority than airway. The nurse and care team must carefully consider the plan of care to provide both stimulation and also time for adequate rest.
(d) is incorrect because risk for infection is a high priority but not more concerning than airway.
Question 2.
The nurse in the pediatric burn unit is caring for a toddler who sustained burns to both lower extremities due to scalding bath water. When caring for this child, which nursing intervention will assist with preventing contractures of the legs?
(a) Applying knee splints
(b) Elevating the foot of the bed
(c) Hyperextending the toddler’s palms
(d) Performing shoulder range of motion exercises twice daily
Answer:
(a) Applying knee splints
Explanation:
Contractures are limitation of muscle and ligament motion due to burns, injury, or immobility. To prevent contractures, joints should be kept in a neutral position. Application of knee splints will hold the knees in a functional position and prevent contracture of the knee joints. Other nursing interventions to prevent contractures include applying shoes to prevent foot drop and providing range of motion (ROM) activities with each dressing change. The nurse determines whether to provide active or passive ROM based on the extent of tissue damage and the client’s ability to move their own extremity.
Rationale:
(b) is incorrect because elevating the foot of the bed can help reduce edema but will not prevent contractures.
(c) is incorrect because hyperextending any joint for an extended time can, cause contractures, and the palms are not at risk for contractures in a child who sustained burns to the lower extremities.
(d) is incorrect because shoulder range of motion exercises will not prevent contractures of the legs.
Question 3.
The parents of a 12-year-old girl bring her to the healthcare provider’s office for a severe sunburn. When instructing the parents regarding
adequate skin protection, which of the following is best for preventing future skin damage?
(a) “Minimize your child’s sun exposure from 1 to 4 p.m., when the sun is at its strongest.”
(b) “Use sunscreen with sun protection factor of 6 or more and cover all parts of the body.”
(c) “Apply sunscreen regularly, even when the weather is overcast.”
(d) “When you go to the beach, sit in the shade to prevent sunburn.”
Answer:
(c) “Apply sunscreen regularly, even when the weather is overcast.”
Explanation:
Sunscreen is most effective at preventing skin damage when it is used consistently, even when it is overcast.
Rationale:
(a) is incorrect because sun exposure should be minimized between 10 am and 2 pm, when the sun is strongest.
(b) is incorrect because SPF 15 or greater should be recommended and should be applied to all skin that is potentially going to be exposed to the sun.
(d) is incorrect because sitting in shade while at the beach is not as effective at preventing sunburn as regularly using SPF of 15 or greater.
Question 4.
A 13-year-old boy is in the dermatology clinic with his parents for psoriasis. When assessing the affected areas, which of the following types of secondary lesions does the nurse expect to find?
(a) Scale
(b) Crust
(c) Ulcer
(d) Scar
Answer:
(a) Scale
Explanation:
Psoriasis is caused by an autoimmune disease that leads to red, raised, thick, itchy plaques on the skin covered by silvery-white scales with symmetrical distribution. These lesions are most commonly found on the elbows, knees, scalp, sacrum, and behind the ears. Scales are secondary lesions in psoriasis.
Rationale:
(b) is incorrect because crust is not found with psoriasis.
(c) is incorrect because ulcers are not found with psoriasis.
(d) is incorrect because scars may be present on the skin from previous outbreaks but are not a secondary lesion found with psoriasis.
Question 5.
The nurse is planning to administer dexamethasone topical cream to a school-age child with dermatitis on the anterior chest. How does the nurse apply the topical agent?
(a) Using a circular motion to enhance absorption
(b) Upward motion to increase blood supply to the affected area
(c) Long, even, outward, and downward strokes
(d) After washing the affected area with soap and warm water
Answer:
(c) Long, even, outward, and downward strokes
Explanation:
In a child with eczematous dermatitis (or atopic dermatitis), the nurse will note rough, dry, erythematous skin lesions that progress to weeping and crusting. Skin may appear blistered and swollen. Topical steroids and antihistamine agents should be applied beginning at the midline and using long, even, outward, and downward strokes to reduce follicle irritation and skin inflammation. The client’s fingernails should be kept short and clean, and non-irritating loose cotton clothing should be worn to minimize itching and discomfort.
Rationale:
(a) is incorrect because using a circular motion can cause follicle irritation and skin inflammation.
(b) is incorrect because upward motion can cause follicle irritation and skin inflammation.
(d) is incorrect because soap can be irritating to the skin in a patient with eczema. A warm colloid bath solution is best for cleansing the skin, if necessary.
Question 6.
A 9-year-old girl is admitted to the emergency room for frostbite to the toes after playing in the snow for several hours. When assessing the girl, which of the following characteristics would the nurse expect to find?
(a) Gangrenous, edematous toes
(b) Bright red skin and nail beds edematous
(c) Slurred speech
(d) White skin insensitive to touch
Answer:
(d) White skin insensitive to touch
Explanation:
Frostbite occurs when skin and possibly underlying tissues are exposed to cold temperatures for a prolonged period of time. Skin that is frostbitten is white or blue in color, and the skin is cold, hard, and insensitive to touch. Frostbite is common on the ears, nose, cheeks, chin, fingers, and toes.
Rationale:
(a) is incorrect because edema is characteristic of frostbite, but gangrene is a late complication which does not appear after several hours of cold exposure.
(b) is incorrect because bright red skin and edematous nailbeds are not characteristic of frostbite.
(c) is incorrect because slurred speech is characteristic of hypothermia, not specifically frostbite.
Question 7.
The nurse is caring for four patients on the pediatric medical unit. Which patient needs to be evaluated for wound infection?
(a) Patient with a uniform bed of granulation tissue across the wound
(b) Patient whose wound has thin, serous drainage
(c) Patient whose white blood cell count was 24,000/mm3 this morning
(d) Patient whose wound is decreasing in size
Answer:
(c) Patient whose white blood cell count was 24,000/mm3 this morning
Explanation:
Normal white blood cell (WBC) count is 4,500-10,000/mm3. An elevated WBC count indicates possible infection, so this patient should be assessed for wound infection. Other indications of wound infection include viscous/purulent drainage, discoloration of tissue within the wound and at the wound margins, or unexpected pain during dressing change or when the dressing is in place.
Rationale:
(a) is incorrect because a uniform bed of granulation tissue suggests the 'wound is healing properly. An indication of wound infection is strips of granulation tissue at the base of the wound.
(b) is incorrect because thin, serous drainage from a wound is not an indication of wound infection.
(d) is incorrect because a wound decreasing in size is not an indication of wound infection.
Question 8.
A 16-year-old boy in the clinic has multiple lesions of the skin. Which of the following lesions should be evaluated by the nurse first?
(a) Beige freckles on the hands and arms
(b) Lower leg mole, irregular shape, blue with white specks
(c) Cluster of pustules to the left axilla
(d) Red, thick pustules with white scales on the chest
Answer:
(b) Lower leg mole, irregular shape, blue with white specks
Explanation:
A mole that is irregular and blue with white specks fits criteria for possibly being precancerous or cancerous and must be investigated immediately. The criteria for cancer include variation of color in one lesion, irregular border, size greater than 6mm, and change in appearance or new symptom.
Rationale:
(a) is incorrect because freckles are benign.
(c) is incorrect because pustules indicate possible infection, but a potential cancerous lesion should be assessed first.
(d) is incorrect because red, thick pustules with white scales describe psoriasis, which is chronic and autoimmune, and not the nurse’s greatest priority.
Question 9.
The nurse is documenting a wound assessment for a 7-year-old boy who was injured in a motor vehicle accident. The nurse notes the presence of a scab on a deep wound. Which phase of wound healing does the nurse identify this as?
(a) Inflammatory
(b) Migratory
(c) Proliferative
(d) Maturation
Answer:
(b) Migratory
Explanation:
Wound healing progresses through several stages including inflammation, proliferation, migration, and reepithelialization. Scab formation occurs in the migratory phase due to epithelial cell migration, fibroblast synthesis of scar tissue, and new cells developing across a wound.
Rationale:
(a) is incorrect because during the inflammatory stage, the scab has not yet formed. The inflammatory stage is marked by redness and swelling while damaged and dead cells are cleared out, along with bacteria and other pathogens or debris. White blood cells engulf debris within the wound by the process of phagocytosis during the inflammatory stage.
(c) is incorrect because the scab has not yet formed in the proliferative stage. This stage of wound healing is characterized by granulation tissue filling the wound and contraction of the wound edges.
(d) is incorrect because the maturation phase is sloughing off of the scab and return of the skin to normal.
Question 10.
The nurse in the pediatric unit is caring for a toddler with severe impetigo. Which of the following interventions does the nurse include in the child’s plan of care?
(a) Placing mitts on the child’s hands
(b) Administering systemic antibiotics
(c) Applying topical antibiotics
(d) Continuing to administer antibiotics for 21 days as prescribed
Answer:
(b) Administering systemic antibiotics
Explanation:
Impetigo is a superficial skin infection due to beta-hemolytic streptococci or staphylococci and is contagious. Severe impetigo requires 7 to 10 days of systemic antibiotics to prevent glomerulonephritis.
Rationale:
(a) is incorrect because the toddler’s nails should be trimmed to prevent scratching. Mitts are used for infants with impetigo to prevent secondary infection, but mitts should be avoided with toddlers because they are a form of restraint, and the toddler can follow directions and be discouraged from scratching.
(c) is incorrect because topical antibiotics are not as effective for severe impetigo.
(d) is incorrect because antibiotics are administered for 7 to 10 days.
Question 11.
The nurse in the pediatric emergency room admits a 10-year-old boy with external bleeding from the right lower extremity. What is the nurse’s initial intervention?
(a) Elevation of the extremity
(b) Pressure point control
(c) Application of direct pressure
(d) Application of a tourniquet
Answer:
(c) Application of direct pressure
Explanation:
Direct pressure application is the first step in controlling external bleeding. Placing direct pressure on the wound restricts blood flow manually. The nurse should use a sterile barrier (such as gauze) to help reduce the risk for infection while applying direct pressure to the point of bleeding.
Rationale:
(a) is incorrect because elevation reduces flow to the affected extremity and can decrease bleeding, but direct pressure must be applied to the site of hemorrhage before elevation.
(b) is incorrect because pressure point control is used only after direct pressure and elevation fail to control the bleeding. Pressure point control involves constricting the major artery that feeds the point of the bleed. A major risk of using the pressure point method is necrosis below the point of constriction.
(d) is incorrect because a tourniquet (band tied tightly around the limb to restrict blood flow) is only used to decrease bleeding if all other measures have failed. Often times, a tourniquet can fail to stop bleeding and even increase bleeding by impairing venous blood flow.
Question 12.
The father of a 7-year-old boy calls the clinic nurse to report that his son has come into contact with poison ivy. When the father asks the nurse if there is a treatment that can prevent the poison ivy rash from occurring, what is the first question the nurse should ask?
(a) “Have you had your son take a shower?”
(b) “Does your son have any sign of a rash yet?”
(c) “Do you have any oral or topical antihistamines on hand?”
(d) “Is your son allergic to poison ivy?”
Answer:
(a) “Have you had your son take a shower?”
Explanation:
When poison ivy sap comes into contact with skin, it’s oil, urushiol, forms an invisible film on skin. Up to 85 percent of Americans will develop an allergic contact dermatitis rash when directly in contact with this oil. Showering with copious lathering and rinsing is the first intervention after coming in contact with poison ivy, so this is the first question that should be asked.
Rationale:
(b) is incorrect because the rash from poison ivy does not occur immediately after contact. Itchy blisters or a streaky red rash may occur within hours up to 2 days after contact, and usually last 1 to 2 weeks. The blisters may weep and eventually crust over.
(c) is incorrect because antihistamines are not used until after the skin has been thoroughly washed and all clothing which may have come into contact with the poison ivy has been changed.
(d) is incorrect because it is an inappropriate question for the nurse to ask and will not necessarily be helpful at this time. Not all individuals are allergic to the oil (urushiol) from a poison ivy plant, but people rarely know if they are allergic or not (roughly 75 to 85 percent of people are allergic).
Question 13.
The community health nurse has provided education regarding prevention of Lyme disease. Which statement by a child indicates more teaching is needed?
(a) “We shouldn’t use insect repellants because they attract ticks.”
(b) “Wearing long-sleeved tops and pants is important.”
(c) “We should wear hats when we go hiking.”
(d) “We should wear closed-toed shoes and socks that can be pulled up over our pants.”
Answer:
(a) “We shouldn’t use insect repellants because they attract ticks.”
Explanation:
Lyme disease is a bacterial disease caused by Borrelia burgdorferi and transmitted to humans from infected ticks. The best way to prevent Lyme disease is to avoid wooded areas with tall grass. Prevention of Lyme disease also includes wearing insect repellant (20% DEET or higher is recommended), wearing long-sleeved tops and pants, wearing hats, and closed-toed shoes and long socks pulled over the pants. Gloves may also be worn, tucked into the sleeves of the shirt to prevent ticks from crawling up the wrists.
Rationale:
(b) is incorrect because wearing long-sleeved tops and pants will help prevent Lyme disease. Clothing should be changed after spending time outdoors, as ticks may remain on clothing for several hours before attaching to the skin.
(c) is incorrect because wearing hats will help prevent ticks from hiding in the hair and potentially attaching to the scalp.
(d) is incorrect because wearing closed-toed shoes and long socks will prevent Lyme disease.
Question 14.
The student nurse in the pediatric intensive care unit (ICU) is learning about monitoring for cyanosis in dark-skinned children. The student learns that the area least optimal to assess for cyanosis is:
(a) Nail beds
(b) Lips
(c) Sclera of the eye
(d) Tongue
Answer:
(c) Sclera of the eye
Explanation:
Cyanosis occurs when an increased amount of unoxygenated blood circulates. Cyanosis reflects compromised oxygen saturation and causes a blue-gray or whitish tinge to the lips, tongue, oral mucosa, nail beds, conjunctivae, and palms and soles of the hands and feet in dark-skinned children. The nurse may also observe for cyanotic skin color changes over the cheekbones and on the earlobes. The sclera is not optimal for assessing for cyanosis in dark-skinned children. (Note: other indications of decreased tissue perfusion include cold, clammy skin, a rapid, thread pulse, and rapid, shallow respirations.)
Rationale:
(a) is incorrect because nail beds are appropriate to assess for cyanosis.
(b) is incorrect because lips are appropriate to assess for cyanosis.
(d) is incorrect because the tongue is appropriate to assess for cyanosis.
Question 15.
The nurse in the pediatric clinic is assessing a 4-year-old child with folliculitis. Which of the following assessment findings does the nurse expect?
(a) Bullous formations on the skin
(b) Deep localized infection
(c) Numbness at the infection site
(d) Reddened, raised hair follicles
Answer:
(d) Reddened, raised hair follicles
Explanation:
Folliculitis is inflammation of hair follicles due to infection of either bacterial or fungal origin. It appears as reddened, raised hair follicles. Lesions may be superficial or deep. Single or multiple papules or pustules may appear within or close to the hair follicles. Folliculitis most commonly appears within a man’s beard, or on the legs of ladies who shave. Other areas include the axillae, trunk, or buttocks.
Rationale:
(a) is incorrect because bullous formations (large, fluid-filled vesicles) on the skin is characteristic of impetigo, often caused by S. aureus. The face, hands, and neck are most commonly involved, and the bullae can rupture, leaving raw, reddened areas. Impetigo is highly contagious.
(b) is incorrect because deep localized infection is characteristic of cellulitis. Skin will appear swollen, red, hot, and tender, and often pits when pressed by the fingertips. When cellulitis affects deep tissues under the skin, it can become a systemic, life-threatening infection.
(c) is incorrect because folliculitis is characterized by itching and soreness at the infection site.
Question 16.
A 9-year-old girl is in the family practice clinic with impetigo. When instructing the parents on how to care for the skin infection, which of the following does the nurse recommend?
(a) Squeezing of vesicles
(b) Antibiotics
(c) Soaking in an ice bath
(d) Placing gloves on the child to prevent scratching
Answer:
(b) Antibiotics
Explanation:
Impetigo is a superficial skin infection due to beta-hemolytic streptococci and is contagious. Crusts must be gently removed from vesicles in order for topical antibiotics (polysporin or bacitracin) to work to clear the infection. Topical antibiotics are generally used for treating impetigo when it is limited to a small area; however, systemic antibiotics may be needed if reduce the contagious spread and treat deep infection.
Rationale:
(a) is incorrect because squeezing of vesicles is not recommended as this can increase the spread of impetigo and cause unnecessary pain.
(c) is incorrect because soaking in an ice bath is not recommended. The „ nurse should teach the patient with impetigo to wash the lesions with a warm soap solution or to use povidone-iodine or chlorhexidine to remove the crust and effect the central site of bacterial growth.
(d) is incorrect because placing gloves on the child is not necessary. As impetigo is highly contagious, the infected child should avoid contact with other children or individuals at risk for infection until 24 hours after the antibiotic therapy has begun. The parent or healthcare provider should wear gloves when caring for the lesions of a child with impetigo.
Question 17.
The parents of a 6-month-old have brought the infant to the pediatric clinic for diaper rash. Which of the following suggestions does the nurse make to assist with improving the diaper rash?
(a) Change diapers less often
(b) Apply steroid cream
(c) Apply talc
(d) Apply skin barrier cream
Answer:
(d) Apply skin barrier cream
Explanation:
Diaper rash is inflammation and irritation of the skin in the perineal or groin area due to constant exposure to wetness. Skin contact with urine or feces containing urea, enzymes, and bacteria combined with a baby’s sensitive skin can contribute to diaper rash. Other causative factors include the beginning of the introduction of solid foods to infants, diapers and clothes that are too tight, and the use of antibiotics. More frequent diaper changes, exposing the area to air, skin barrier cream, and cornstarch are all recommended treatments for diaper rash.
Rationale:
(a) is incorrect because diapers should be changed more often, every 2 to 3 hours to prevent diaper rash.
(b) is incorrect because steroid creams are not recommended to treat diaper rash unless specifically prescribed by the healthcare provider.
(c) is incorrect because talc is not recommended. Parents should also be encouraged to use a soft cloth moistened with water, instead of prepackaged wet wipes, as these wipes may contain chemicals that are irritating to the skin and can worsen diaper rash.
Question 18.
The nurse in the pediatric clinic is caring for a 6-year-old boy with tinea corporis. Which of the following interventions does the nurse perform for this condition?
(a) Systemic antibiotics
(b) Skin scrub with betadine
(c) Topical therapy
(d) Radiotherapy
Answer:
(c) Topical therapy
Explanation:
Tinea corporis is a fungal infection of the skin (ringworm of the body, not on the feet or scalp). This superficial condition is characterized by annular, raised rings on the skin. Tinea corporis is typically treated with topical therapy with -azole drugs or allylamines. Affected areas should be washed frequently and kept clean and dry. Other types of tinea include tinea pedis (athlete’s foot) and tinea capitis (ringworm on the scalp).
Rationale:
(a) is incorrect because systemic antibiotics are not usually used, as ringworm is caused by a fungus. Antibiotics will only be needed if the initial infection causes a secondary bacterial, more extensive infection.
(b) is incorrect because betadine scrub is not indicated for tinea corporis.
(d) is incorrect because radiotherapy is not indicated for tinea corporis. Radiotherapy (teletherapy) can be internal or external radiation treatment used for some cancers, not fungal infections.
Question 19.
A nurse is preparing to see a 4-year-old child in the pediatric unit with atopic dermatitis. Which of the following manifestations does the nurse expect to find?
(a) Inflamed, red, swollen, itchy skin
(b) Annular, raised rings
(c) Pustules
(d) Smooth, red skin
Answer:
(a) Inflamed, red, swollen, itchy skin
Explanation:
Atopic dermatitis (eczema) is a red rash that evolves rapidly and is blistered and swollen. It appears as inflamed, red, swollen, and itchy skin. The skin lesions may progress to weeping and crusting. Parents should be taught to eliminate offending foods in the child’s diet which may cause the eczema, such as milk, eggs, wheat, citrus fruits, or tomatoes. Irritating clothing (rough fabric or wool) that promotes sweating can also trigger eczema in children. Cotton clothing is best. Soap and long or hot baths and showers should be avoided. Topical steroids and antihistamines may be used to treat eczema.
Rationale:
(b) is incorrect because annular, raised rings are characteristic of tinea corporis, ringworm fungal infection of skin on the body (not the scalp or feet).
(c) is incorrect because pustules are not characteristic of eczema. Pustules are commonly seen with folliculitis, impetigo, or acne vulgaris.
(d) is incorrect because skin affected by eczema is rough and dry.
Question 20.
The parents of a 6-year-old boy diagnosed with eczema ask the nurse how the skin condition occurs. What is the best response by the nurse?
(a) “Eczema is caused by irritants such as poison ivy.”
(b) “Eczema is caused by a trigger antigen and the inflammatory process.”
(c) “It is a genetic condition.”
(d) “It is caused by varicella.”
Answer:
(b) “Eczema is caused by a trigger antigen and the inflammatory process.”
Explanation:
Atopic dermatitis or eczema is a red rash that evolves rapidly and is blistered and swollen. Eczema is started by a trigger antigen which leads to the inflammatory process, rash, and itching due to the rash. The trigger antigen may be a certain food in the diet (commonly milk, eggs, wheat, citrus fruits, or tomatoes) or by tight, irritating clothing such as wool, which can promote sweating.
Rationale:
(a) is incorrect because poison ivy causes allergic eczema, not atopic dermatitis.
(c) is incorrect because eczema may be a precursor to adult asthma or hay fever but is not genetic.
(d) is incorrect because varicella does not cause eczema.
Question 21.
The nurse is preparing to admit a 9-year-old boy with varicella-zoster. What type of isolation precautions does the nurse implement?
(a) Positive pressure isolation room
(b) Only standard precautions
(c) Airborne precautions
(d) Droplet precautions
Answer:
(c) Airborne precautions
Explanation:
Varicella-zoster, or chicken pox, is an infection of the skin caused by the varicella-zoster virus. The nurse should implement airborne and contact precautions as varicella-zoster is spread through coughing, sneezing, and saliva, as well as contact with blisters or contaminated objects. Prodromal signs include a slight fever, malaise, and decreased appetite. The rash associated with varicella-zoster is pruritic and begins as macule, then progresses to a papule, and then a vesicle. Successive crops of all three stages may be present at any one time. Other findings include lymphadenopathy and elevated temperature.
Rationale:
(a) is incorrect because varicella-zoster requires airborne precautions until the lesions are crusted over. Airborne precautions involve the use of a negative-pressure isolation room, in which contaminated air from the patient’s room is removed via a pressurized system that does not allow that air to circulate back through the hospital’s ventilatory system.
(b) is incorrect because standard precautions are not enough when caring for a patient with varicella-zoster.
(d) is incorrect because varicella-zoster is not spread by droplet transmission.
Question 22.
A father calls the pediatric clinic to speak with the nurse about his 5- year-old daughter who has cold symptoms, fever, and red bumps all over the body. Which of the following does the nurse suspect?
(a) Eczema
(b) Impetigo
(c) Tinea corporis
(d) Varicella-zoster
Answer:
(d) Varicella-zoster
Explanation:
Varicella-zoster, or chicken pox, is an infection of the skin caused by the varicella-zoster virus. It is characterized by cold symptoms, fever, and red bumps all over the body.
Rationale:
(a) is incorrect because eczema is generally found on the cheeks, scalp, in elbow joints, and behind the knees, not all over the body.
(b) is incorrect because impetigo is characterized by reddish-colored macules which turn into honey-colored crusted vesicles.
(c) is incorrect because tinea corporis, a fungal infection, is characterized by annular, raised rings on the skin.
Question 23.
The nursing student is learning about acne vulgaris. The student learns which ages are most often affected by acne vulgaris?
(a) 15-18 years
(b) 1-3 years
(c) 4-6 years
(d) 7-10 years
Answer:
(a) 15-18 years
Explanation:
Acne vulgaris is blockage and inflammation of hair follicles and sebaceous glands, most commonly affecting the skin on the face, back, neck, and chest. Blackheads, whiteheads, papules, pustules, and cysts are common. Children most affected by acne vulgaris ae ages 15 to 18 years. Treatment includes PO tetracycline and other antibiotic agents. Nursing considerations include providing emotional support and monitoring for secondary infection.
Rationale:
(b) is incorrect because l to 3-year-old children do not commonly get acne vulgaris.
(c) is incorrect because 4 to 6-year-olds do not get acne vulgaris.
(d) is incorrect because 7 to 10-year-olds can begin to develop acne vulgaris but are not most often affected by it.
Question 24.
A 16-year-old boy is in the family practice clinic for acne vulgaris. When the boy asks the nurse the best way to deal with the acne, what does the nurse recommend?
(a) Squeeze the pustules
(b) Wash the skin with hot water
(c) Alcohol rinse
(d) Benzoyl peroxide
Answer:
(d) Benzoyl peroxide
Explanation:
Acne vulgaris is blockage and inflammation of hair follicles and sebaceous glands affecting the face, back, neck, and chest. Treatment includes benzoyl peroxide, typically applied to the affected areas in gel, cream, or liquid, in concentrations of 2.5% increasing through 5.0%, and up to 10%. Other medications may include tetracycline antibiotics, retinoid-like agents, and hormones. Nursing priorities include teaching the adolescent about good nutrition and hygiene and providing emotional support.
Rationale:
(a) is incorrect because squeezing acne pustules can worsen acne, prolong healing and cause unnecessary pain.
(b) is incorrect because hot water can worsen acne.
(c) is incorrect because alcohol is irritating to the skin and can worsen acne.
Question 25.
The nurse in the family practice clinic is caring for a 14-year-old with acne vulgaris who is concerned about his appearance. Which of the following nursing diagnoses does the nurse implement for this patient?
(a) Activity intolerance related to acne vulgaris
(b) Disturbed body image related to acne vulgaris
(c) Skin infection related to acne vulgaris
(d) Deficient knowledge related to acne vulgaris
Answer:
(b) Disturbed body image related to acne vulgaris
Explanation:
Acne vulgaris is blockage and inflammation of hair follicles and sebaceous glands affecting the face, back, and chest. This can cause psychological distress due to the appearance of pustules and redness of the skin. Disturbed body image is the most appropriate nursing diagnosis for this adolescent related to his concern about his appearance.
Rationale:
(a) is incorrect because activity intolerance is not common in adolescents experiencing acne.
(c) is incorrect because skin infection is not a nursing diagnosis.
(d) is incorrect because the adolescent is expressing concern about his image, not a lack of knowledge about acne or its treatment plan.