Nokea
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?
- A. Place the child in a quiet environment
- B. Make a list of foods that the child likes
- C. Encourage the parents to rest when possible
- D. Apply lotion to hands and feet
Correct Answer: A
Rationale: The correct intervention for a child with Kawasaki disease, presenting with irritability and skin peeling, is to place the child in a quiet environment. This helps reduce environmental stimuli, calming the child and aiding in managing the symptoms associated with the disease. Choice B is incorrect as addressing food preferences is not the priority in this situation. Choice C is incorrect as the focus should be on the child's immediate needs. Choice D is incorrect as applying lotion is not the first-line intervention for Kawasaki disease symptoms.
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A 4-year-old child with a history of asthma is brought to the clinic with a complaint of cough and wheezing. The nurse notes that the child has been using a rescue inhaler more frequently over the past week. What should the nurse do next?
- A. Review the child's asthma action plan
- B. Administer a dose of the rescue inhaler
- C. Instruct the parents to increase the dose of the controller medication
- D. Schedule a follow-up appointment in one week
Correct Answer: A
Rationale: In this scenario, the best course of action for the nurse is to review the child's asthma action plan. By doing so, the nurse can assess the current asthma management, ensure that the child is using the rescue inhaler correctly, and make any necessary adjustments to the treatment plan. Reviewing the asthma action plan helps in identifying triggers, proper use of medications, and when to seek medical help. Administering a dose of the rescue inhaler without assessing the current management plan may not address the underlying issue. Instructing the parents to increase the dose of the controller medication without proper evaluation can lead to inappropriate medication adjustments. Scheduling a follow-up appointment in one week is not the immediate action needed to address the child's current symptoms.
The healthcare provider is preparing to administer digoxin (Lanoxin) to a 6-month-old infant with heart failure. The healthcare provider notes that the infant's heart rate is 90 beats per minute. What should the healthcare provider do next?
- A. Administer the medication as prescribed
- B. Hold the medication and notify the healthcare provider
- C. Reassess the heart rate in 30 minutes
- D. Administer half the prescribed dose
Correct Answer: B
Rationale: In this scenario, the correct action is to hold the medication and notify the healthcare provider. Digoxin should be withheld if the infant's heart rate is below 100 beats per minute. Administering digoxin in this situation can further slow down the heart rate in infants with heart failure, leading to potential adverse effects. Reassessing the heart rate in 30 minutes is not the best immediate action to take, as prompt notification and withholding of the medication are crucial. Administering the medication as prescribed or giving half the dose can exacerbate the situation by potentially further lowering the heart rate.
Which statement by a school-aged client going to summer camp indicates the best understanding of the mode of transmission of Lyme disease?
- A. I'll cover my mouth with a wet cloth if there's too much dust blowing.
- B. Cuts and scrapes need to be washed out and covered right away.
- C. I'm not going to swim where the water is standing still or feels too hot.
- D. I have to wear long sleeves and pants when we're hiking around the pond.
Correct Answer: D
Rationale: The correct answer is D. Wearing long sleeves and pants helps prevent tick bites, which can transmit Lyme disease. Ticks carrying Lyme disease are often found in wooded or grassy areas, so covering exposed skin can reduce the risk of being bitten by an infected tick. Choices A, B, and C do not address the specific mode of transmission of Lyme disease through tick bites, making them incorrect.
During a follow-up clinical visit, a mother tells the nurse that her 5-month-old son, who had surgical correction for tetralogy of Fallot, has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held, and his growth is in the expected range. Which intervention should the nurse implement?
- A. Stimulate the infant to cry to produce cyanosis
- B. Auscultate the heart and lungs while holding the infant
- C. Evaluate the infant for failure to thrive
- D. Obtain a 12-lead electrocardiogram
Correct Answer: B
Rationale: Auscultating the heart and lungs while the infant is held is the most appropriate intervention to assess his current condition. This action allows the nurse to gather important information regarding the cardiovascular and respiratory status of the infant, which is crucial in evaluating his post-surgical recovery and overall well-being. Option A is incorrect as stimulating the infant to cry intentionally is not necessary and could cause distress. Option C is incorrect as the infant's growth is within the expected range, indicating no signs of failure to thrive. Option D is incorrect as obtaining a 12-lead electrocardiogram is not the initial intervention needed in this situation; assessing the heart and lungs through auscultation is more immediate and informative.
What information should be reinforced with the parents about introducing solid foods to their infant?
- A. Begin with one tablespoon of the food.
- B. Introduce each food 4 to 7 days apart.
- C. Mix the new food with rice cereal.
- D. Remove foods when the infant refuses them.
Correct Answer: B
Rationale: The correct answer is B. Introducing solid foods 4 to 7 days apart is crucial as it allows time to identify any allergic reactions or intolerances to specific foods. This gradual introduction helps parents monitor their infant's response to new foods and pinpoint any potential issues, ensuring the infant's safety and well-being. Choices A, C, and D are incorrect because starting with one tablespoon of the food, mixing new food with rice cereal, and removing foods when the infant refuses them are not recommended practices for introducing solid foods to infants.