A nurse is caring for a child who has Kawasaki disease.

Which of the following systems should the nurse monitor in response to this diagnosis?

Gastrointestinal

Integumentary

Respiratory

Cardiovascular

Answer and Explanation

The Correct Answer is D

Choice A rationale
While gastrointestinal symptoms can occur in Kawasaki disease, such as diarrhea, vomiting, and abdominal pain, the primary system affected is not the gastrointestinal system.
Choice B rationale
Although Kawasaki disease can cause symptoms such as a rash and changes in the lips and oral cavity, which are related to the integumentary system, the primary system affected is not the integumentary system.
Choice C rationale
Respiratory symptoms are not typically a primary concern in Kawasaki disease. While a child with Kawasaki disease may have some respiratory symptoms such as a cough and runny nose, these are not the main focus of monitoring.
Choice D rationale
Kawasaki disease is a systemic vasculitis that predominantly affects the cardiovascular system. It is the leading cause of acquired heart disease in children. Therefore, monitoring the cardiovascular system is crucial in managing a child with Kawasaki disease.

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Correct Answer is D

Explanation

Step 1 is: Calculate the Apgar score based on the given vital signs. The Apgar score is calculated based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color.

Step 2 is: Assign points for each criterion. For heart rate of 160 bpm, assign 2 points. For good, vigorous respiratory effort, assign 2 points. For active movement and well-flexed muscle tone, assign 2 points. For crying with stimulation of soles of feet (reflex irritability), assign 2 points. For body pink but feet and hands cyanotic (color), assign 1 point.

Step 3 is: Add up the points. 2 (heart rate) + 2 (respiratory effort) + 2 (muscle tone) + 2 (reflex irritability) + 1 (color) = 9 points. So, the correct Apgar score for this newborn is 9.

A. Deep tendon reflexes of +1 B. Blood pressure 148/98 mm Hg C. 1+ pitting sacral edema D. 3+ protein in the urine .

Correct Answer is A

Explanation

Choice A rationale
Deep tendon reflexes of +1 are not consistent with preeclampsia. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of kidney damage. One of the symptoms can be hyperreflexia, or overly active reflexes, not diminished reflexes.
Choice B rationale
Blood pressure of 148/98 mm Hg is consistent with preeclampsia, as one of the defining features of preeclampsia is high blood pressure.
Choice C rationale
1+ pitting sacral edema is consistent with preeclampsia. Edema, or swelling, is a common symptom of preeclampsia.
Choice D rationale
3+ protein in the urine is consistent with preeclampsia. One of the defining features of preeclampsia is the presence of excess protein in urine (proteinuria), which indicates kidney problems. Deep vein thrombosis Deep vein thrombosis Explore

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A nurse is caring for a child who has Kawasaki disease. Which of the following systems should the nurse monitor in response to this diagnosis?

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Correct Answer is D

Explanation

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

Correct Answer is A

Explanation

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A nurse is caring for a child who has Kawasaki disease.

Which of the following systems should the nurse monitor in response to this diagnosis?