for a child with kawasaki disease which symptom is most indicative of the acute phase
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Nursing Elites

ATI RN

ATI Nursing Care of Children 2019 B

1. For a child with Kawasaki disease, which symptom is most indicative of the acute phase?

Correct answer: A

Rationale: The correct answer is A: Strawberry tongue. In Kawasaki disease, a 'strawberry tongue' is most indicative of the acute phase. This refers to the tongue appearing red and swollen with enlarged fungiform papillae, giving it a strawberry-like appearance. Joint pain (Choice B) is more commonly associated with other conditions like rheumatoid arthritis. Rash (Choice C) and peeling skin (Choice D) are also seen in Kawasaki disease but are not as specific to the acute phase as the presence of a strawberry tongue.

2. A 3-year-old child, previously potty-trained, becomes a bed-wetter again during a hospital stay. Which explanation should the nurse provide to the parents?

Correct answer: C

Rationale: During a hospital stay, preschool children may exhibit regression in behaviors such as bed-wetting due to stress. It is important for parents to understand that this behavior is a common response to the hospital environment and should resolve once the child is back home. Therefore, the correct explanation for the nurse to provide to the parents is choice C. Choice A is incorrect because it inaccurately states that the child is no longer potty-trained. Choice B is incorrect as it assumes a medical issue without evidence. Choice D is incorrect as it dismisses the parents' concerns without addressing the underlying cause of the behavior.

3. What factor predisposes an infant to fluid imbalances?

Correct answer: C

Rationale: Infants have immature kidneys that are less efficient at concentrating urine, making them more susceptible to fluid imbalances. Their higher surface area to volume ratio also contributes to greater insensible fluid losses.

4. At a well-visit, a mother voices concern that her 30-month-old has a smaller vocabulary than other children in his daycare. The nurse should:

Correct answer: B

Rationale: When a parent expresses concern about a child's development, it is essential to conduct a comprehensive assessment of all areas of development before jumping to conclusions. Choosing option B allows the nurse to evaluate the child for other age-appropriate developmental milestones to determine if there are any delays or concerns. Admitting the child to the hospital (option A) is not necessary at this point and may cause unnecessary stress. Suggesting hearing impairment (option C) without proper evaluation can lead to misdiagnosis. Explaining a significant developmental delay (option D) should only be done after a thorough assessment and diagnosis.

5. The nurse is describing clinical reasoning to a group of nursing students. Which is most descriptive of clinical reasoning?

Correct answer: A

Rationale: Clinical reasoning is purposeful and goal-directed, involving the use of critical thinking and decision-making skills to provide effective patient care.

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