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 A

Explanation

The nurse should report the findings of significant erythema and swelling in the scrotum immediately to the healthcare provider. The adolescent's symptoms may be indicative of testicular torsion, which is a medical emergency and requires prompt treatment to prevent loss of the testicle. Obtaining a swab of secretions from the penis and urethra or collecting a sterile urine sample for culture and sensitivity are not appropriate actions for this presentation. Providing a urinal for urinary hesitancy may be appropriate if the adolescent is experiencing difficulty urinating, but this should not take precedence over reporting the findings to the healthcare provider.

A. Breast milk provides adequate calories for the child. B. Regular syringe feedings promote rapid weight gain. C. High-calorie formula encourages increased growth. D. Fruit juice increases the child's daily vitamin intake.

Correct Answer is C

Explanation

The nurse should recognize that the statement "high-calorie formula encourages increased growth" is an appropriate understanding of interventions for an infant with FTT. High-calorie formula can help infants who are not gaining weight adequately to increase their calorie intake and promote growth.

Breast milk provides adequate nutrition for most infants, but in cases of FTT, the infant may require a higher calorie intake than breast milk can provide. Regular syringe feedings and fruit juice are not recommended interventions for FTT. Syringe feedings can cause aspiration and fruit juice does not provide the appropriate balance of nutrients needed for an infant's growth and development.

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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?

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Naxlex Comprehensive Predictor Exams

A male adolescent arrives at the clinic and reports intense pain in the testicular area that occurred during football practice at high school. The nurse observes the scrotum and identifies significant erythema and swelling. Which action should the nurse take?

Correct Answer is A

Explanation

The nurse is providing nutrition education to the parents of an infant with failure to thrive (FTT). Which statement made by the parent should the nurse recognize as an appropriate understanding of interventions?

Correct Answer is C

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?