UNIT 6: CASE STUDY 5 (Nursing Care of a Family When a Child Has an Note that the course pack

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Infectious Disorder) is intended only for the use
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course that you are enrolled
CASE STUDY: AN ADOLESCENT WITH INFECTIOUS MONONUCLEOSIS in. It is not for distribution
or sale. Permission should
be obtained from your
Lynalyn is a 14-year-old who comes to the school health office reporting instructor for any use other
she has a sore throat. than for what it is intended.

CHIEF CONCERN:
“I feel like I'm swallowing broken glass my throat is so sore.”

HISTORY OF CHIEF CONCERN:

Child began feeling “listless” 1 week ago and noticed a pink macular rash on arms and trunk.
Developed a sore throat 4 days ago. Didn't take temperature but thinks it has been elevated.
Temperature is 101.8° orally now.

FAMILY PROFILE:
Child is youngest of three children (a brother 24, a sister 18). Child lives with parents in a
lakeside condominium. Parents own a doughnut franchise; Lynalyn works at the counter most
evenings after school; attends dance class every Monday evening.

HISTORY OF PAST ILLNESSES:

Had roseola at 2 months of age; contracted Lyme disease last year on school field trip.

HISTORY OF FAMILY ILLNESSES:

Aunt with breast cancer; cousin who is HIV positive from receiving a transfusion.

DAY HISTORY:
Nutrition: Eats a vegetarian diet along with parents.
Sleep: Sleeps 6 hours per night; no problems.
Recreation/Play: Belongs to drama and computer clubs at school.
Growth and Development: Lynalyn is a sophomore in high school (class is age appropriate);
taking a college-entrance curriculum. Currently dating a high school senior. Admits to being sex-
ually active; takes prescribed birth control pill daily. Has taken dance lessons since age 4; active
in drama club; starred in spring musical at school.

REVIEW OF SYSTEMS:
Essentially negative but for chief concern.
Genito-urinary: Menarche at 11 years; menstrual cycle 28 days; menses for 5 days.

PHYSICAL EXAMINATION
General Appearance: Well proportioned, listless appearing 14-year-old female holding hand
over anterior throat.
Weight: 112 pounds (50th percentile). Height: 5 feet 5 inches (75th percentile). BMI: 18.6
Blood pressure: 120/72
Head: Normocephalic; hair is full and well bodied; no tenderness over sinuses.
Eyes: Red reflex present; follows to all fields of vision; slightly reddened conjunctivae.
Nose: Midline septum; no discharge
Ears: TMs pink; landmarks present; moderate amount cerumen in both canals. Hearing is equal
to examiner’s.
Mouth: Teeth in good alignment; 2 repaired cavities; none at present.
Throat: Bright red, tonsillar tissue swollen; white pus present in crypts. Mucous membrane dry.
Filmy exudate covering posterior throat.
Neck: Midline trachea; thyroid not enlarged; two palpable submaxillary lymph nodes on right
side. No pain on forward flexion.
Lungs: Coarse rhonchi in both upper lobes; respiratory rate: 20 breaths per minute.
Heart: Rate: 80 beats per minute; no murmurs
Abdomen: Spleen palpable 3 cm under left costal margin; bowel sounds present in all quadrants;
no masses. Scattered pink macular rash evident on abdomen.
Back: Spine is in good alignment; no tenderness over vertebrae.
Genitalia: Deferred
Extremities: No inflammation of joints; full ROM. A fading ecchymotic area (yellow/brown) 2 x 1
cm present over left tibia. A ¼ cm gray, irregular lesion on right index finger.
Neuro: DTRs 2+; Kernig’s sign negative. Babinski negative. Sensory and motor function grossly
intact.

Lynalyn is referred to the school physician and diagnosed with infectious mononucleosis. She is
advised to maintain bed rest for 2 weeks.

CASE STUDY QUESTIONS:

INSTRUCTION: Select the best answer. For every answer that you choose, write, or indicate the
rationale. You will earn 2 points for every item you answered correctly. Do not forget to include
your references here.

1. Infectious mononucleosis is called the “kissing disease” because it is spread by oral contact.
The organism that causes the disease is:
a. streptococcal Type A.
b. the Epstein-Barr virus.
c. staphylococcus Type B.
d. any one of the retroviruses.
Answer:
Infectious mononucleosis, "mono," "kissing disease," and glandular fever are all terms popularly
used for the very common illness caused by the Epstein-Barr virus (EBV).

2. A precaution you would stress with Lynalyn because she has infectious mononucleosis
would be:
a. do not lift heavy weights to try and reduce cardiac stress.
b. do not break open the rash crusts as this could leave scars.
c. avoid high protein foods until liver inflammation fades.
d. do not play contact sports until the size of the spleen declines.
Answer:
Caution them to avoid contact sports as long as their spleen is enlarged.

3. Infants receive immunoglobulins from their mothers to help protect them against infectious
diseases. This form of immunity is termed:
 a. active immunity.
b. toxoid immunity.
c. vaccine immunity.
d. passive immunity.
Answer:
In prenatal life, it diffuses across the placenta to supply passive immune protection to the fetus
and until the infant can effectively produce immunoglobulins.

4. Many diseases are infectious during the prodromal period. The prodromal period is the time
between:
a. invasion of the organism and beginning of symptoms.
b. beginning of symptoms and the time of treatment.
c. unspecific and specific symptoms.
d. when the rash of the illness tends to occur.
Answer:
A prodromal period is a time between the beginning of nonspecific symptoms and disease-
specific ones.

5. Many childhood disorders have skin rashes (exanthems). If a rash is flat with the level of the
skin, you could chart this as a:
a. macule.
b. vesicle.
c. papule.
d. wheal.
Answer:
The lesions are discrete, rose-pink macules approximately 2 to 3 mm in size. They fade on
pressure and occur most prominently on the trunk.

6. Roseola infantum is a frequent infection of infants. The mark of this disorder is that the:
a. rash appears only after the fever declines.
b. buccal membrane is covered with blue spots.
c. rash, although it looks bright red is not pruritic.
d. rash is most obvious on the palms of the hands.
Answer:
After 3 or 4 days, the fever falls abruptly, and a distinctive rash appears.

7. Measles epidemics frequently appear on college campuses in students who did not receive
measles immunization as young children. A distinctive finding in measles is that the:
a. rash is pustular with yellow, oozing crusts.
b. buccal membrane is covered with blue spots.
c. rash, although it looks bright red is not pruritic.
d. rash is most obvious on the palms of the hands.
Answer:
Koplik’s spots (small, irregular, bright-red spots with a blue-white center point) appear on the
buccal membrane. Koplik’s spots distinguish the disease because none of the other exanthems
has this finding.
 8. Varicella (chickenpox) also has a distinctive rash. A mark of a varicella rash is that the:
a. rash, although it looks bright red, is not pruritic.
b. rash is most obvious on the palms of the hands.
c. rash is present in all four stages at one time.
d. crusts that form are as infectious as nasal secretions.
Answer:
At one time, all four stages of lesions (macule, papule, vesicle, and crust) are present.

9. Herpes zoster is a disorder caused by the same type virus as varicella. The mark of the rash
for herpes zoster is that the rash:
a. although it looks bright red, is not pruritic.
b. is most obvious on the palms of the hands.
c. is present in all four stages at one time.
d. follows the course or path of peripheral nerves.
Answer:
The first manifestations are pruritus and cutaneous vesicular lesions on erythematous bases that
follow the distributions of the lumbar and thoracic nerves (usually on the trunk, face, or upper
back) and cause deep nagging pain.

10. You would expect to see which drug prescribed to relieve herpes zoster lesions?
a. Penicillin
b. Prednisone
c. Acyclovir
d. Dilantin
Answer:
Treatment for herpes zoster includes measures to reduce pruritus and analgesia for pain.
Acyclovir, which inhibits viral DNA synthesis, may be effective in limiting the disease.

11. Lynalyn has a wart on her hand. These are annoying lesions caused by a long-incubating
virus. The over-the-counter medication parents can purchase for this is:
a. Acyclovir.
b. Cepacol.
c. Compound W (salicylic acid).
d. Treatment H.
Answer:
Parents can use over-the-counter wart-removing preparations, such as Compound W, to
dissolve them. Application of 40% salicylic acid may be prescribed to remove plantar warts.

12. Mumps (infectious parotitis) can be distinguished from a simple swollen lymph nodes
because:
a. mumps causes painful swallowing.
b. parotid-gland swelling is above the jaw line.
c. mumps has an accompanying red rash.
d. mumps also causes a “strawberry tongue.”
Answer:
It is often difficult to differentiate mumps from submaxillary adenitis (swelling of lymph nodes).
The best method of differentiation is to place a hand along the child’s jaw line. If the major
amount of swelling is above the hand, it is probably mumps. If the largest amount of swelling is
below the hand line, it is probably adenitis.

13. Why is it especially important to prevent mumps (infectious parotitis) in boys?

a. Mumps can result in paralysis of the lower extremities.
b. The virus can cause testicular damage and sterility.
c. The virus is more active if testosterone is present.
d. Mumps can be associated with male pattern baldness.
Answer:
Mumps is a potentially serious illness because several serious complications can occur. If mumps
orchitis develops, it is generally unilateral. A single testis swells rapidly and is painful and tender.
When the fever declines, testicular swelling also decreases, although the tenderness may exist
for weeks. Atrophy of the testis may result leading to a low sperm count. The chance that
mumps orchitis will lead to complete sterility is exaggerated, however (Butel, 2007).

14. Scarlet fever is caused by beta-hemolytic streptococcus type A. Based on this, you
would be certain to caution parents to:
a. be certain to administer the full course of antibiotic.
b. not allow the child to swim for 4 weeks afterward.
c. not press on her abdomen because her spleen is swollen.
d. notice that her skin will remain slightly reddened afterward (scarlet).
Answer:
Because the underlying cause of the illness is a streptococcal infection, a course of penicillin is
prescribed (Travers & Mousdicas, 2008). Caution parents to give the full amount prescribed for
the full course to prevent the complications of beta-hemolytic, group A streptococcal infections
(acute glomerulonephritis or rheumatic fever).

15. Impetigo is an infection seen almost exclusively in children. The appearance of these
lesions is typically:
a. gray, “mole-like” irregular papules.
b. honey-colored oozing crusts.
c. red macular, pruritic lesions.
d. raised, brown spots with red edges.
Answer:
Impetigo is a superficial infection of the skin. It begins as a single papulovesicular lesion
surrounded by localized erythema. As more vesicles appear, they become purulent, ooze, and
form honey-colored crusts.

16. Lynalyn contracted Lyme disease last summer. To help prevent children from
contracting this disease, you would advise them to:
a. wash fresh fruit and vegetables well before eating.
b. wear long pants when hiking near deer trails.
c. wash hands well after using a bathroom.
d. not play near mosquito-infested ponds.
Answer:
One of the suggestions for the parents to help reduce the risk for exposure of their children to
Lyme disease is to wear protective clothing when hiking or playing in wooded areas: long
sleeves, high necklines, long slacks. Tuck bottom of slacks into socks or boots.
 17. A usual nursing diagnosis for a child with a childhood rash would be:
a. risk for injury related to skin atrophy from rash.
b. altered nutrition related to rash invading GI tract.
c. pain related to the pruritus of the accompanying rash.
d. loss of self-esteem related to failed immunization.
Answer:
Providing comfort for the pruritus of skin lesions is important for many childhood infections. No
matter what agent is causing the disease, a rash tends to be extremely itchy and uncomfortable.

18. Cat-scratch disease is an illness that occurs when a child is scratched by an infected cat.
The chief symptom of this is:
a. a single swollen cervical lymph node.
b. high fever and a positive Babinski reflex.
c. gray, “mole-like” irregular papules.
d. a red rash that occurs mainly on the hands.
Answer:
The first symptom for the child is a single skin papule or pustule that lasts 1 to 3 weeks.
Approximately 2 weeks after the scratch, a single but severe local swollen lymph node also
develops. The node most markedly involved is of the head, neck, or axilla. The node
enlargement generally lasts 2 to 3 months.

19. Lynalyn has a history of having had pinworms when she was a preschooler. Pinworms
are best detected:
a. after a bath as warm water calls them to the skin surface.
b. early in the morning as they come out to the skin at night.
c. following a bowel movement as these forces them outward.
d. by inspecting children’s hands as this is how they are spread.
Answer:
At night, the female pinworm migrates down the intestinal tract and out the anus to deposit
eggs on the skin in the anal and perianal region. The movement of the worms causes the anal
area to itch, and the child awakens at night crying and scratching.

20. Tetanus can be a fatal disease in under-immunized children. Tetanus is spread by:
a. coughing and sneezing.
b. fomites such as combs.
c. a tick found on mice.
d. contaminated soil.
Answer:
Tetanus, a highly fatal disease if untreated, is caused by an anaerobic, spore-forming bacillus.
The bacillus, found in soil and the excretions of animals, enters the body through a wound. If the
wound is deep, such as a puncture wound, where the distal end of the wound is shut off from an
oxygen source, the tetanus bacilli begin to reproduce.
REFERENCE:
Pilliterri, A. (2010). Nursing Care of a Family When a Child Has an Infectious Process. In
Lippincott, Williams & Wilkins (Ed). Maternal and Child Health Nursing: Care of the Childbearing
and Childrearing Family 6th Edition (pp. 1260-1287) Philadelphia: Wolters Kluwer Health

Adapted from:
Pillitteri, A. (2010). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing
Family (6th Edition). Lippincott Williams & Williams.

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