A nurse is caring for a 6-year-old child in an emergency department.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Potential Condition: Kawasaki Disease
Kawasaki disease is a systemic vasculitis that primarily affects children under the age of 5 but can occur in older children. It presents with prolonged fever (lasting more than 5 days), conjunctival injection (red eyes without exudate), mucosal inflammation (strawberry tongue, red lips), maculopapular rash, and extremity changes (edema and peeling skin on hands and feet). Elevated inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), high WBC count, and thrombocytosis (elevated platelets) are consistent with Kawasaki disease. If untreated, it can lead to coronary artery aneurysms.
Actions to Take:
Plan to administer high dose of aspirin:
High-dose aspirin is given to reduce inflammation and prevent thrombosis in coronary arteries, as Kawasaki disease increases the risk of coronary artery aneurysms.
Assess for neurological changes:
Neurological changes, such as irritability, can indicate aseptic meningitis or other central nervous system involvement, which can occur in Kawasaki disease.
Parameters to Monitor:
Daily weights:
Monitoring daily weights is essential to assess for fluid retention or overload, as Kawasaki disease can cause myocarditis and cardiac dysfunction.
Reports of chest pain or pressure:
Monitoring for chest pain or pressure is crucial to detect early signs of myocardial ischemia or coronary artery involvement, which are potential complications of Kawasaki disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Battery involves actual physical contact without consent.
B. Negligence refers to failing to provide appropriate care, leading to harm.
C. Assault occurs when a person is threatened with harm or offensive contact, creating fear, even if no physical contact occurs. Telling the client that a catheter will be inserted without consent can be perceived as a threat.
D. Libel is a false written statement that damages someone’s reputation.
Correct Answer is C
Explanation
A. Storing oxygen tanks under the bed is not safe due to limited ventilation and fire hazards.
B. The oxygen gauge should be checked daily, not weekly, to monitor levels.
C. The oxygen tank should be placed away from curtains or drapes to reduce the risk of fire.
D. The oxygen tank wrench should be readily accessible in case of emergencies.
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