A nurse is admitting an infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect?
13% weight loss
Bulging anterior fontanel
Bradypnea
Capillary refill 3 seconds
The Correct Answer is A
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
A.Factor X is a clotting factor involved in the coagulation cascade. It is not directly related to preventing infections. While clotting factors are essential for hemostasis, they do not play a role in infection prevention.
B. Steroids can suppress the immune response, making the child more susceptible to infections. Therefore, they are not specifically administered to prevent infections
C. In a child with a sickle cell crisis who is hospitalized, preventing infections is crucial due to the increased risk of infections in this condition. Administering immunizations that the patient is scheduled for can help prevent certain infections.
Children with sickle cell disease are at a higher risk of bacterial infections, especially from encapsulated organisms like Streptococcus pneumoniae and Haemophilus influenzae. Vaccines can help protect against these pathogens and reduce the risk of serious infections.
Some of the recommended immunizations for children with sickle cell disease include:
Pneumococcal vaccine: This helps protect against infections caused by Streptococcus pneumoniae, which can cause severe respiratory and bloodstream infections.
Haemophilus influenzae type B (Hib) vaccine: This protects against infections caused by Haemophilus influenzae type B, which can lead to serious illnesses like pneumonia and meningitis.
Meningococcal vaccine: This protects against Neisseria meningitidis, which can cause meningitis and bloodstream infections.
Influenza vaccine: This annual vaccine helps protect against seasonal flu, which can be severe in children with sickle cell disease.
Administering these vaccines according to the recommended schedule helps provide protection against certain infections and can improve outcomes for children with sickle cell disease during hospitalization and beyond. The other options, Factor X, steroids, and PCA morphine, are not specific measures for preventing infections in a child with sickle cell crisis.
D.PCA (patient-controlled analgesia) morphine is used for pain management during a sickle cell crisis. It does not directly prevent infections.
Correct Answer is C
Explanation
A. Gastrointestinal:
Kawasaki disease primarily affects blood vessels, and the gastrointestinal system is not the main target of this condition. While gastrointestinal symptoms can occur as part of the overall inflammatory response, such as abdominal pain, vomiting, or diarrhea, they are not the primary focus of concern in Kawasaki disease. The most critical system to monitor in Kawasaki disease is the cardiovascular system, specifically the coronary arteries.
B. Respiratory:
The respiratory system is not the primary system affected by Kawasaki disease. While respiratory symptoms can occur as part of the overall inflammatory response and fever associated with the disease, such as coughing or runny nose, they are not the main concern in Kawasaki disease. The primary system to monitor in this condition is the cardiovascular system, especially the coronary arteries.
C. Cardiovascular:
This is the correct answer. Kawasaki disease is primarily a vasculitis (inflammation of blood vessels) that affects various blood vessels, including the coronary arteries. The inflammation of the coronary arteries can lead to coronary artery aneurysms and other cardiac complications. Monitoring the cardiovascular system is essential to detect any signs of coronary artery involvement and ensure timely intervention to prevent potential long-term cardiac problems.
D. Integumentary:
The integumentary system (skin) is not the primary focus of Kawasaki disease. While some skin changes can occur during the acute phase of the disease, such as a rash or peeling skin on the hands and feet, these are not the primary concerns. Monitoring the cardiovascular system is critical in Kawasaki disease due to the risk of coronary artery inflammation and potential complications.
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