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.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Delegation is important but should follow after establishing goals.

B. Determining goals of the day is the first step in effective time management as it helps prioritize tasks and allocate resources efficiently.

C. Scheduling daily activities is essential but occurs after setting goals.

D. Developing an hourly time frame is a detailed planning step that comes later.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

Transient tachypnea of the newborn: The newborn's elevated respiratory rate and mild grunting are indicative of transient tachypnea, a condition where the baby breathes too fast due to retained lung fluid.
Hypoglycemia: Newborns, especially those with higher birth weights, are at risk for hypoglycemia, which can be exacerbated by stress and increased energy expenditure due to rapid breathing.

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively?

Correct Answer is B

Explanation

A nurse is caring for a newborn. Exhibits SELECT words from the choices below to fill in each blank in the following sentence. The client is at risk for developing ________ and ___________

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

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