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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When advising a new mother on caring for a child with croup, the telephone triage nurse should prioritize concern for difficulty swallowing secretions. This symptom can indicate that the child's airway is becoming obstructed and requires immediate medical attention. A fever of 101.0°F (38.3°C) is a common symptom of croup and can be managed at home with antipyretics. Crying often when nursing is not a specific symptom of croup and may have other causes. A barking cough, worse at night, is a characteristic symptom of croup and can be managed at home with humidified air and hydration.
Correct Answer is C
Explanation
Answer: C. Red blood cell count of 2.3 cells/mcl or (2.3 x 10/L).
Rationale:
A. White blood cell count of 10,000/mm³ (10 x 10⁹/L): This is within the normal range for an infant, indicating no immediate concern for infection or immune response. It does not need to be urgently conveyed to the surgeon.
B. Weight gain of 2 pounds (0.91 kg) since birth: This is a positive sign indicating healthy growth and nutritional status, but it is not a critical concern that would affect the immediate surgical plan.
C. Red blood cell count of 2.3 cells/mcl or (2.3 x 10⁹/L): This low RBC count indicates anemia, which is critical information for the surgeon. Anemia can increase the risk of complications during and after surgery due to potential issues with oxygenation and healing, making it the most important information to convey.
D. Urine specific gravity is 1.011: This indicates normal hydration status and is not immediately relevant to the surgical procedure. It does not need to be urgently reported to the surgeon compared to the low RBC count.
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