A nurse is assessing a 12-year-old client.
Which of the following assessment findings indicates the need for further evaluation regarding cellulitis?
Pustules around the child's mouth.
Scaly patches on the child's face.
Patches of hyperpigmentation on the child's extremities.
Open, weeping lesions on the child's lower legs.
The Correct Answer is D
Cellulitis is a deep bacterial infection of the dermis and subcutaneous tissues. Assessment requires identifying signs of skin barrier compromise and localized inflammation, such as erythema, warmth, and edema, to prevent systemic progression like bacteremia or necrotizing fasciitis.
Choice A rationale
Pustules around the mouth often suggest impetigo, a superficial infection typically caused by Staphylococcus aureus or Streptococcus pyogenes. Cellulitis involves deeper tissue layers and presents with diffuse spreading redness rather than localized perioral pustular clusters.
Choice B rationale
Scaly facial patches are indicative of fungal infections like tinea faciei or inflammatory conditions like seborrheic dermatitis. These lack the acute inflammatory markers of cellulitis, which typically presents with intense warmth, tenderness, and non-circumscribed edema.
Choice C rationale
Hyperpigmentation usually results from chronic venous insufficiency, post-inflammatory changes, or endocrine disorders. Cellulitis is an acute infectious process characterized by rapid-onset erythema and swelling rather than stable changes in skin melanin distribution or pigment deposition.
Choice D rationale
Open, weeping lesions provide a portal of entry for bacteria like Group A Streptococcus into the subcutaneous space. This finding necessitates evaluation for secondary cellulitis, as compromised skin integrity is the primary risk factor for infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Systemic lupus erythematosus is a chronic autoimmune condition characterized by widespread inflammation and tissue damage. Knowledge of disease triggers, including the role of estrogen and physiological stress, is essential for educating adolescent clients on managing flares and maintaining stable health during puberty.
Choice A rationale
Flare-ups involve an exacerbation of symptoms such as joint pain, fever, and rashes, causing the client to feel significantly worse rather than better. Understanding the cyclical nature of the disease helps the client recognize when medical intervention is needed.
Choice B rationale
While triggers vary, many are highly predictable and manageable. Ultraviolet light exposure, emotional stress, and certain infections are well-known triggers that clients can learn to identify and avoid through careful monitoring and lifestyle adjustments.
Choice C rationale
Hormonal shifts, particularly during puberty or menstrual cycles, are known to influence lupus activity. Estrogen is thought to play a role in the immune response, making adolescents more susceptible to flares during these physiological changes.
Choice D rationale
Fatigue is a hallmark symptom of lupus caused by systemic inflammation. Clients are encouraged to balance activity with rest and should not resist the urge to sleep, as adequate rest is vital for managing the body's inflammatory response.
Correct Answer is D
Explanation
Identifying specific clinical manifestations of head trauma is essential for neurosurgical nursing. This question requires knowledge of cranial anatomy and the localized signs of base-of-skull injuries. Recognizing these signs allows for the timely assessment of potential cerebrospinal fluid leaks or hemorrhage.
Choice A rationale
The halo sign occurs when cerebrospinal fluid separates from blood on absorbent material, forming a ring. This confirms the presence of a CSF leak from the ears or nose but does not describe mastoid bruising specifically.
Choice B rationale
Cheyne-Stokes respirations involve an abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing followed by apnea. This indicates severe brainstem injury or increased intracranial pressure rather than a specific fracture location.
Choice C rationale
Raccoon eyes, or periorbital ecchymosis, result from blood tracking into the soft tissue around the eyes. While this indicates a basilar skull fracture, it specifically involves the anterior fossa rather than the mastoid process area.
Choice D rationale
Battle's sign is the classic clinical indicator of a fracture in the posterior cranial fossa. It involves ecchymosis over the mastoid bone. This sign typically appears several days after the initial injury due to vascular extravasation.
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