A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. What should the nurse suggest to remove this material?
Apply powder to absorb the material.
Vigorously scrub the leg.
Carefully pick the material off the leg.
Wash the area with warm water and soap
The Correct Answer is D
When the skin surface is caked with desquamated skin and sebaceous secretions after the removal of a cast, the nurse should suggest washing the area with warm water and soap. This will help to gently cleanse the skin and remove the accumulated material without causing unnecessary trauma or irritation.
Option A, applying powder to absorb the material, may not effectively remove the caked material and could potentially lead to further clumping or discomfort.
Option B, vigorously scrubbing the leg, can be harsh on the skin and may cause skin irritation, redness, or even abrasions. It is important to be gentle and avoid excessive scrubbing, especially on the fragile and recently exposed skin.
Option C, carefully picking the material off the leg, can increase the risk of skin injury or introduce bacteria into the skin. Picking at the skin should be avoided to prevent further damage or infection.
Therefore, option D, washing the area with warm water and soap, is the most appropriate and gentle method to remove the caked material from the skin surface
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Hypothyroidismreferstoanunderactivethyroid glandthatdoesnotproduceenoughthyroidhormones. In newborns, this condition is known as congenital hypothyroidism. Thesymptoms mentioned—mottled skin, a large fontanel (soft spot on the baby's head), a largetongue,lethargy, anddifficultyfeeding—arecharacteristic ofhypothyroidism inneonates.
Mottledskincanoccur duetodecreasedcirculationandlow bodytemperatureassociatedwith hypothyroidism. A large fontanel and tongue are common physical features seen ininfants with hypothyroidism. Lethargy and poor feeding are also typical signs of thiscondition.
Hypoglycaemia in (option A) is incorrect because it refers to low blood sugar levels andusuallypresentswithdifferent symptomssuchas jitteriness,tremors,and sweating.
Hypocalcaemia in (option C) is incorrect because it is low calcium levels and can manifestwithsymptoms like muscle cramps, twitching,and seizures.
Phenylketonuria (PKU) in (option D) it is incorrect because it is a metabolic disordercharacterized by the inability to metabolize the amino acid phenylalanine, and it typicallypresentswith differentsymptoms such asintellectual disabilityandamustydoorto theskin.
Therefore, based on the symptoms described, hypothyroidism (B) is the most likely disorderinthisneonate. Itisimportanttoconsultahealthcareprofessionalforaproperdiagnosisandappropriatetreatment.
Correct Answer is A
Explanation
A change in status that should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury is confusion and altered mental status. As intracranial pressure increases, it can affect brain function and lead to neurological changes, including confusion, disorientation, irritability, decreased level of consciousness, or other alterations in mental status. These changes indicate that the brain is being compressed and compromised, and immediate intervention is required.
Option B, increased diastolic pressure with narrowing pulse pressure in (option B) is incorrect because it, can be a sign of increased ICP, but it is not specific to head injuries and can be influenced by other factors such as pain, anxiety, or systemic conditions. It is important to consider the overall hemodynamic status of the child and assess for additional signs and symptoms of increased ICP.
irregular, rapid heart rate in (option C), can be a sign of increased ICP, but it is not specific to head injuries and can be influenced by other factors such as pain, anxiety, or other medical conditions. Assessment of heart rate should be considered along with other signs and symptoms of increased ICP.
rapid, shallow breathing, in (option D) can be a sign of increased ICP, but it is not specific to head injuries and can be influenced by other factors such as pain, anxiety, or respiratory conditions. Respiratory assessment should be considered along with other signs and symptoms of increased ICP.
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