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. Apply lotion to hands and feet.
- B. Encourage the parents to rest when possible.
- C. Make a list of foods that the child likes.
- D. Place the child in a quiet environment.
Correct Answer: D
Rationale: Placing the child in a quiet environment reduces stimulation and promotes rest, addressing irritability, a primary symptom of Kawasaki disease.
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While checking the vital signs of a 10-year-old child who underwent a tonsillectomy earlier in the day, the nurse notices the child swallowing every 2 to 3 minutes. What action should the nurse take next?
- A. Check for signs of teeth clenching or grinding
- B. Inspect the back of the throat
- C. Stimulate the gag reflex by touching the tonsillar pillars
- D. Ask the child to speak to assess for any changes in voice tone .
Correct Answer: B
Rationale: Frequent swallowing may indicate post-tonsillectomy bleeding, requiring throat inspection.
The nurse is assessing the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?
- A. Recognizes most letters and numbers
- B. Uses 1-word sentences
- C. Speaks in simple sentences with four or more words
- D. Uses gestures with 1 to 2-word sentences .
Correct Answer: C
Rationale: Simple sentences with four or more words are expected for a 3-year-old's language development.
A nurse is educating parents about essential dietary modifications for their child, who has recently been diagnosed with celiac disease. Which foods should the nurse include in the list of permissible foods for this child?
- A. Rice
- B. Barley
- C. Rye
- D. Oats
Correct Answer: A
Rationale: Rice is gluten-free and safe for celiac disease, unlike barley, rye, or most oats.
A male adolescent comes to the clinic reporting severe testicular pain that started during a high school football practice. The nurse notes significant redness and swelling of the scrotum. What should the nurse do next?
- A. Provide the adolescent with a urinal for urinary hesitancy
- B. Immediately report the findings to the healthcare provider
- C. Collect a sterile urine sample for culture and sensitivity
- D. Obtain a swab of secretions from the penis and urethra
Correct Answer: B
Rationale: Severe testicular pain with redness and swelling suggests testicular torsion, a medical emergency requiring immediate reporting to the healthcare provider.
The nurse is evaluating a preschool-aged child who is presenting with symptoms of flank pain, dysuria, and a low-grade fever. What additional information should the nurse obtain from the parent to determine if the child might have a urinary tract infection?
- A. Frequency of urination
- B. Any recent changes in diet
- C. Presence of any unusual odors in the urine
- D. Any changes in the color of the urine
Correct Answer: A
Rationale: Increased urination frequency is a common UTI symptom in children, aiding diagnosis.
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