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 C

Explanation

The startle reﬂex, also known as the Moro reﬂex, is a normal reﬂex in infants that is present at birth and usually disappears by 3-4 months of age. The reﬂex is elicited by a sudden loud noise or change in position, and the infant will extend their arms and legs, then bring them back in towards their body.

If a 6-month-old infant is still demonstrating the startle reﬂex, it may indicate a developmental delay or neurological issue and requires further evaluation by the nurse or healthcare provider.

The other responses are all normal developmental milestones for a 6-month-old infant. By 6 months of age, most infants will have doubled their birth weight, enjoy playing games like peek-a-boo, and have developed the ability to turn their head to locate sounds.

A. Inspect the posterior oropharynx. B. Touch the tonsillar pillars to stimulate the gag reﬂex. C. Ask the child to speak to evaluate change in voice tone. D. Assess for teeth clenching or grinding.

Correct Answer is A

Explanation

The nurse should inspect the posterior oropharynx of a child who is frequently swallowing after tonsillectomy to assess for bleeding or the presence of clots. Swallowing frequently can be a sign of postoperative bleeding, which is a potential complication of tonsillectomy.

Touching the tonsillar pillars to stimulate the gag reﬂex or asking the child to speak would not provide information about the presence of bleeding.

Assessing for teeth clenching or grinding is not related to this particular observation.

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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 is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

Correct Answer is C

Explanation

While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?

Correct Answer is A

Explanation

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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?

The nurse is caring for a child with sickle cell disease who is experiencing a sickle cell crisis. Which finding should the nurse report to the healthcare provider immediately?

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?