a nurse is assessing a child who has kawasaki disease which of the following findings should the nurse expect

ATI RN

ATI Pediatric Proctored Exam 2023

1. A child is being assessed for Kawasaki disease. Which of the following findings should be expected?

A. Decreased heart rate
B. Dry, scaly skin
C. Fever unresponsive to antipyretics
D. Nontender cervical lymphadenopathy

Correct answer: C

Rationale: In Kawasaki disease, a child typically presents with a fever that is unresponsive to antipyretics because the disease is characterized by systemic inflammation. The persistent fever is a hallmark feature of the disease and can last for more than five days despite treatment with antipyretics.

2. A parent of an infant with gastroesophageal reflux is being taught by a nurse. Which of the following instructions should the nurse include in the teaching?

A. Offer the infant feedings every 2 hours.
B. Position the infant upright after feedings.
C. Feed the infant thickened formula.
D. Place the infant in a prone position after feedings.

Correct answer: B

Rationale: Correct posture after feedings is crucial for an infant with gastroesophageal reflux to reduce the risk of regurgitation. Placing the infant upright helps prevent the backflow of stomach contents into the esophagus, minimizing symptoms of reflux.

3. A pediatric client is admitted to the emergency department with a traumatic brain injury (TBI) that caused a loss of consciousness. The last set of vital signs showed heart rate 48, blood pressure (BP) 148/74 mmHg, respiratory rate 28 and irregular. What does the nurse suspect based on these data?

A. Spinal cord injury
B. Increased intracranial pressure
C. Typical for sleep
D. Improvement

Correct answer: B

Rationale: The vital signs of bradycardia, hypertension, and irregular respirations indicate increased intracranial pressure. Bradycardia (heart rate of 48), hypertension (blood pressure of 148/74 mmHg), and irregular respirations are typical signs of increased intracranial pressure in a pediatric client with a traumatic brain injury and loss of consciousness.

4. Which question provides information regarding a child's community mobility?

A. What is the level of supervision provided?
B. Can the child leave the house and play with friends?
C. Is the child being bullied?
D. Is there equipment available so the child can play with peers?

Correct answer: B

Rationale: Choice B directly assesses the child's community mobility by inquiring about their ability to leave the house and engage in play activities with friends. Community mobility involves the child's independence in social and recreational activities outside the home, making this question crucial for understanding their daily functioning and autonomy.

5. A patient taking sildenafil (Viagra) asks a nurse what action to take if priapism occurs. Which response should the nurse provide?

A. Take an additional half-strength dose of sildenafil
B. The condition usually resolves in 12 hours or less
C. Wait until the following day and notify the doctor
D. Seek emergency help, because permanent damage can occur

Correct answer: D

Rationale: Patients experiencing priapism from sildenafil should seek immediate medical attention. Priapism is a serious condition where an erection lasts longer than 4 hours, and if left untreated, it can lead to irreversible damage to the penile tissue, potentially causing permanent erectile dysfunction. Therefore, prompt intervention is crucial to prevent long-term complications.