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. Picking up a pencil demonstrates the ability to use which of the following?

Correct answer: A

Rationale: Picking up a pencil requires the use of the pincer grasp, which involves the coordination of the thumb and forefinger to hold small objects. The pincer grasp is a fine motor skill essential for tasks that necessitate precision and dexterity. Choices B, C, and D are incorrect. Prehension refers to the act of grasping or holding an object, parachute reflex is a protective response to sudden movement or loss of support, and grasp reflex is an automatic closing of the hand when an object is placed in the palm, none of which specifically relate to the action of picking up a pencil.

3. Which clinical manifestations should the nurse anticipate when assessing a child for hypoglycemia?

Correct answer: D

Rationale: The correct answer is D: 'Shaky feeling and dizziness.' Hypoglycemia in children often presents with symptoms like shakiness, dizziness, sweating, hunger, and irritability. These symptoms occur because the brain and body are deprived of the glucose they need to function properly. Choices A, B, and C are incorrect because lethargy, thirst, nausea, and vomiting are not typically primary manifestations of hypoglycemia in children.

4. The nurse is preparing to administer an intramuscular injection to a toddler-age client. Which is the most appropriate statement by the nurse prior to this procedure?

Correct answer: C

Rationale: The correct answer is C because it acknowledges the child's feelings, provides clear instructions, and offers comfort and rewards to help the child cope with the procedure. Choice A is not appropriate as it may create anxiety about the injection. Choice B uses the term 'magic,' which may confuse the child and lead to fear. Choice D introduces a fantasy element that may not be beneficial in preparing the child for the injection.

5. The nurse is planning care for a patient with a different ethnic background. Which should be an appropriate goal?

Correct answer: A

Rationale: Adapting ethnic practices to health needs respects the patient's cultural background while ensuring that care is effective and culturally sensitive.

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