A three-year-old is admitted to the pediatric medical unit with acute Kawasaki disease. What signs and symptoms are you most likely to note as you do your intake assessment?
Murmur, tachycardia, low erythrocyte sedimentation rate
Abdominal pain, vomiting, restlessness
Coarse breath sounds, abnormal ECG, and joint pain
Fever, "strawberry tongue" and peeling palms and soles
The Correct Answer is D
Choice A reason: Murmur, tachycardia, and low erythrocyte sedimentation rate are not specific signs of Kawasaki disease. They may indicate other cardiac or inflammatory conditions.
Choice B reason: Abdominal pain, vomiting, and restlessness are not typical signs of Kawasaki disease. They may suggest other gastrointestinal or neurological problems.
Choice C reason: Coarse breath sounds, abnormal ECG, and joint pain are not common signs of Kawasaki disease. They may indicate other respiratory, cardiac, or rheumatic disorders.
Choice D reason: This is the correct choice. Fever, "strawberry tongue" and peeling palms and soles are characteristic signs of Kawasaki disease, which is a rare but serious condition that causes inflammation of the blood vessels. Other signs include red eyes, swollen lips, rash, and swollen lymph nodes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement is correct, as most infants are ready to start solid foods when they are 4 to 6 months old, depending on their individual growth and readiness. The nurse should explain to the parents that some signs of readiness include being able to hold the head up, sit with support, show interest in food, and move food from the spoon to the throat.
Choice B reason: This statement is incorrect, as 2 to 3 months is too early to introduce solid foods to infants, as their digestive system and swallowing skills are not mature enough to handle them. The nurse should advise the parents to avoid giving solid foods before 4 months of age, as it can increase the risk of choking, allergies, obesity, and iron deficiency.
Choice C reason: This statement is incorrect, as 1 year is too late to introduce solid foods to infants, as they need more nutrients and calories than breast milk or formula alone can provide. The nurse should inform the parents that delaying solid foods beyond 6 months of age can lead to growth faltering, micronutrient deficiencies, and feeding difficulties.
Choice D reason: This statement is incorrect, as 10 to 11 months is too late to introduce solid foods to infants, as they need more nutrients and calories than breast milk or formula alone can provide. The nurse should inform the parents that delaying solid foods beyond 6 months of age can lead to growth faltering, micronutrient deficiencies, and feeding difficulties.
Correct Answer is C
Explanation
Choice A reason: This statement is incorrect, as maceration is not a clinical manifestation of scabies, but a condition of softening and breaking down of the skin due to prolonged exposure to moisture. Maceration can occur in areas where the skin folds or rubs together, such as the groin, armpits, or under the breasts.
Choice B reason: This statement is incorrect, as edema is not a clinical manifestation of scabies, but a condition of swelling due to excess fluid accumulation in the tissues. Edema can occur in various parts of the body, such as the legs, feet, hands, or face, due to various causes, such as heart failure, kidney disease, or allergic reactions.
Choice C reason: This statement is correct, as itching is the primary clinical manifestation of scabies, a contagious skin infection caused by the mite Sarcoptes scabiei. The mite burrows into the skin and lays eggs, causing an intense inflammatory response and pruritus. The itching is usually worse at night and affects the areas between the fingers, wrists, elbows, armpits, waist, buttocks, and genitals.
Choice D reason: This statement is incorrect, as severe pain is not a clinical manifestation of scabies, but a subjective sensation of physical discomfort or distress. Pain can occur in various parts of the body due to various causes, such as injury, inflammation, infection, or disease. Pain can be acute or chronic, and can be rated on a scale of 0 to 10.
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