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 A
Explanation
A. Flumazenil is the antidote for benzodiazepine overdose and should be administered to reverse the effects of diazepam.
B. Monitoring the IV site is important but not an immediate priority in this situation.
C. Seizure precautions are not the primary concern after benzodiazepine overdose.
D. Evaluating for suicidal behavior is important but comes after stabilizing the client.
Correct Answer is D
Explanation
A. "I had to retire because my boss didn't like me.": Indicates projection, attributing personal feelings to someone else.
B. "There were lay-offs at my company, so I journaled about what I accomplished during my career.": Indicates positive coping, not compensation.
C. "I'm so glad I've retired because the work was making me sick and depressed.": Indicates rationalization, justifying the situation.
D. "Since I retired, I have entered many gardening competitions.": The client is compensating for the loss of work-related identity by engaging in competitive gardening, a constructive coping strategy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.