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 D
Explanation
A. The catheter should be picked up carefully, but the length from the tip is less important than maintaining sterility.
B. Cleansing the area is typically done with a single clean swab in a circular motion from the urethral meatus outward.
C. The correct technique for cleaning the penis is a circular motion from the urethra outward, not side-to-side.
D. Lifting the penis perpendicular to the body helps straighten the urethra, making catheter insertion easier and reducing the risk of injury.
Correct Answer is A
Explanation
A. Using an ultrasound picture as a focal point is an effective nonpharmacological distraction technique for managing labor pain.
B. Biofeedback requires prior training and is not typically initiated during labor.
C. Acupuncture requires a specialist and is not commonly initiated by nurses during labor.
D. Transcutaneous electrical nerve stimulation (TENS) is typically used for back pain rather than pelvic pressure.
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