Author Question: A nurse is working with a child who has a chronic skin disorder consisting of many vesicles and ... (Read 49 times)

bclement10 · **on:** Jun 28, 2018

A nurse is working with a child who has a chronic skin disorder consisting of many vesicles and pustules. Which nursing assessment indicates that a priority long-term goal has been met?

A.
Child states that he no longer gets teased at school because of his appearance.
B.
Parents and child verbalize acceptance of disease process and need for medication.
C.
Patient participates in sporting events and other after school-activities regularly.
D.
Skin around primary lesions remains free of redness, warmth, swelling, and pain.

Question 2

A mother-baby nurse is demonstrating swaddling a neonate as a method of keeping the baby warm. The mother asks why she needs to be so careful about the baby's temperature.

Which response by the nurse is the most appropriate?
A.
After being in your womb for 9 months, this is how the baby prefers to stay.
B.
Babies' immune systems are immature; any cold breeze will make them sick.
C.
Their skin is thin and they have little fat, so it's hard to control their temperature.
D.
You need to keep their temperature above what we call normal to keep them well.

reversalruiz · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: D
All options show evidence of positive outcomes. However, physical needs take priority over psychosocial needs, so absence of infection is evidence that a priority goal has been met. Secondary infection can occur due to scratching, picking, and the presence of the lesions themselves.

Answer to Question 2

ANS: C
Babies have thin skin, a large body surface area, scanty subcutaneous fat, and immature neurological systems. All these factors combined make it difficult for a baby to regulate his or her temperature. The other statements are not factual or informative.