A nurse is caring for a 6-year-old child in an emergency department.

Exhibits

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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

A. Place the client in an upright position leaning over a bedside table – This position allows for optimal access to the pleural space and facilitates gravity-assisted drainage of pleural fluid.

B. Inform the client they will be sedated for the procedure – Thoracentesis is typically performed under local anesthesia, not sedation, unless the client has specific complications or needs.

C. Obtain informed consent from the client – Thoracentesis is an invasive procedure, and informed consent is required to ensure the client understands the risks, benefits, and alternatives.

D. Explain that a needle will be inserted in the pleural space to withdraw fluid – Providing a clear explanation of the procedure helps reduce anxiety and ensures the client understands what to expect.

E. Administer a cough suppressant to the client prior to the procedure – A cough suppressant can help prevent the client from coughing during the procedure, reducing the risk of complications such as needle displacement or injury.

F. Inform the client that they will need to fast 4 hr prior to the procedure – Fasting is not required for a thoracentesis. This procedure is usually performed with the client awake and does not involve general anesthesia.

A. A client who requests to sit in the bedside chair while watching TV. B. A client who consumes all the food from their meal tray. C. A client who requests assistance to use the bedside commode. D. A client who has a prescription for compression stockings and did not receive them.

Correct Answer is D

Explanation

A. Requesting to sit in a chair is a normal activity and doesn't indicate a concern.

B. Consuming food from the meal tray is a normal activity and does not require reporting.

C. Requesting assistance to use the bedside commode is a normal activity and does not require reporting unless there is a change in condition.

D. Failing to receive prescribed compression stockings is an important issue because it can increase the risk of deep vein thrombosis (DVT), and it needs to be reported.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse working in the emergency department (ED) is admitting a client. Exhibits The nurse is preparing the client for a thoracentesis. Select the 4 actions that the nurse should take.

Correct Answer is ["A","C","D","E"]

Explanation

A nurse and an assistive personnel (AP) are assigned a group of clients on the unit. Which of the following clients should the nurse instruct the AP to report to the nurse?

Correct Answer is D

Explanation

A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?

A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring. The cardiac rhythm strip shows a wavy baseline, no distinguishable P waves, and an increased heart rate. The nurse should identify the cardiac rhythm as which of the following?

A nurse is caring for a client in the emergency department. Exhibits Select the 4 interventions nurse should take.

A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?

A nurse is teaching dietary guidelines to a client who has celiac disease. Which of the following food choices is appropriate for this client?

A nurse is teaching a client about a variety of stress management techniques. Which of the following instructions by the nurse is appropriate?

A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following findings should the nurse identify as the priority?