A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet.

Which intervention should the nurse instruct the mother to implement first?

Apply lotion to hands and feet.

Encourage the child to rest when possible.

Place the child in a quiet environment.

Make a list of foods that the child likes.

Answer and Explanation

The Correct Answer is C

The nurse should instruct the mother to place the child in a quiet environment first. Kawasaki disease is an illness that can cause inﬂammation in the blood vessels and can lead to symptoms such as irritability and skin peeling. Placing the child in a quiet environment can help reduce stimulation and promote rest, which can help improve the child's symptoms. The other options (A, B, and D) may also be helpful, but placing the child in a quiet environment is a key intervention in this situation.

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Correct Answer is D

Explanation

The nurse should implement the intervention of including the child's toy in the collection of information when the child screams and tries to hide behind the parent, dropping a stuﬀed toy. This can help engage the child and make them feel more comfortable during the medical history collection process. The other options (A, B, and C) are not appropriate interventions in this situation.

A. Rebound tenderness in the left lower abdominal quadrant. B. Stool that consists of mucus and blood. C. Olive-size mass in the epigastric area. D. Frequent burping accompanied by poor feeding.

Correct Answer is C

Explanation

In a 5-week-old infant presenting with a history of projectile vomiting after feedings, the nurse should expect to assess an olive-size mass in the epigastric area. This finding is consistent with pyloric stenosis, a condition in which the muscle at the bottom of the stomach that controls the ﬂow of food into the small intestine becomes thickened and narrowed.

Rebound tenderness in the left lower abdominal quadrant, stool that consists of mucus and blood, and frequent burping accompanied by poor feeding are not typically associated with pyloric stenosis.

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A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse begins collecting the medical history of a child when the child screams and tries to hide behind the parent, dropping a stuﬀed toy. Which intervention should the nurse implement?

Correct Answer is D

Explanation

The nurse is caring for a 5-week-old infant presenting with a history of projectile vomiting after feedings. Which additional finding should the nurse expect to assess?

Correct Answer is C

Explanation

The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces (60 mL) of orange juice. What should the nurse do next?

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The nurse is caring for an infant who was recently diagnosed with a congenital heart defect. Which assessment finding is most important for the nurse to report to the healthcare provider?

A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet.

Which intervention should the nurse instruct the mother to implement first?