Nokea
The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect?
- A. It is also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat, and nose), skin, and lymph nodes.
- B. In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain.
- C. Kawasaki disease occurs most often in boys, children younger than age 5, and children of Hispanic descent.
- D. Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks.
Correct Answer: C
Rationale: The correct answer is C. Kawasaki disease occurs most often in boys and children younger than age 5, but there is no specific predisposition to children of Hispanic descent. Choice A is accurate, as Kawasaki disease does affect mucous membranes, skin, and lymph nodes. Choice B is correct, as peeling of the skin on the hands and feet with joint and abdominal pain are findings in the second phase of the disease. Choice D is accurate since initially, there is a sudden high fever that lasts 1 to 2 weeks.
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Which of these findings would the nurse most closely associate with anemia in a 10-month-old infant?
- A. Hemoglobin level of 12 g/dL
- B. Pale mucosa of the eyelids and lips
- C. Hypoactivity
- D. A heart rate between 140 to 160
Correct Answer: B
Rationale: The correct answer is B. Pale mucosa of the eyelids and lips is a classic sign of anemia in infants, indicating a lack of sufficient red blood cells. This finding is due to decreased hemoglobin levels, which causes reduced oxygen delivery to tissues. Choices A, C, and D are less specific to anemia in infants. While a hemoglobin level of 12 g/dL may be within the normal range for a 10-month-old infant, the presence of pale mucosa is a more indicative sign of anemia.
A nurse is reinforcing teaching with a client who has cancer about foods that prevent protein-energy malnutrition. Which of the following foods should the nurse include in the teaching? (Select one that doesn't apply).
- A. Cottage cheese
- B. Milkshake
- C. Tuna fish
- D. Strawberries and bananas
Correct Answer: D
Rationale: The correct answer is D - Strawberries and bananas. Cottage cheese, milkshakes, and tuna fish are high in protein and calories, making them beneficial in preventing protein-energy malnutrition. However, strawberries and bananas are not as protein or calorie-dense compared to the other options, so they are not as effective in preventing malnutrition.
A nurse is reinforcing teaching with the mother of a 9-month-old infant regarding appropriate dietary choices. Which of the following observations by the nurse indicates a need for further teaching?
- A. The infant eats the same foods prepared for the rest of the family.
- B. The mother gives the infant finger foods, such as apple slices for a snack.
- C. The infant drinks 2 quarts of whole milk a day.
- D. The infant drinks from a cup with a cover.
Correct Answer: C
Rationale: The correct answer is C. Infants should not consume more than 24 ounces of milk a day as it can lead to iron deficiency anemia and other issues. Choices A and B demonstrate appropriate dietary choices for a 9-month-old, as they involve providing the infant with family foods and appropriate finger foods. Choice D is also appropriate as it shows the infant is transitioning to drinking from a cup.
Which of these nursing assessments would be the highest priority for a client at risk for aspiration pneumonia?
- A. Assessing the client's level of consciousness
- B. Monitoring the client's oxygen saturation
- C. Checking the client's gag reflex before eating or drinking
- D. Monitoring the client's intake and output
Correct Answer: C
Rationale: Checking the client's gag reflex before eating or drinking is the highest priority for a client at risk for aspiration pneumonia. Aspiration pneumonia can occur when food, liquids, or saliva are inhaled into the lungs, leading to inflammation or infection. Checking the gag reflex helps prevent the aspiration of substances into the lungs. Assessing the client's level of consciousness (Choice A) is important but not as immediately critical as checking the gag reflex. Monitoring oxygen saturation (Choice B) is essential for respiratory assessment but does not directly prevent aspiration. Monitoring intake and output (Choice D) is important for overall client management but does not specifically address the risk of aspiration pneumonia.
A 4-year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?
- A. Notify the healthcare provider
- B. Readjust the traction
- C. Administer the ordered PRN medication
- D. Reassess the foot in fifteen minutes
Correct Answer: A
Rationale: In this situation, a pale foot with the absence of a pulse indicates compromised circulation, which is a critical emergency. The nurse should immediately notify the healthcare provider to address the circulation issue promptly. Reading the question and understanding the urgency is vital. Readjusting the traction, administering PRN medication, or waiting to reassess the foot in fifteen minutes are not appropriate actions when a child is experiencing compromised circulation.