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

Respiratory

Cardiovascular

Integumentary

Answer and Explanation

The Correct Answer is C

A. Gastrointestinal:

Kawasaki disease primarily affects blood vessels, and the gastrointestinal system is not the main target of this condition. While gastrointestinal symptoms can occur as part of the overall inflammatory response, such as abdominal pain, vomiting, or diarrhea, they are not the primary focus of concern in Kawasaki disease. The most critical system to monitor in Kawasaki disease is the cardiovascular system, specifically the coronary arteries.

B. Respiratory:

The respiratory system is not the primary system affected by Kawasaki disease. While respiratory symptoms can occur as part of the overall inflammatory response and fever associated with the disease, such as coughing or runny nose, they are not the main concern in Kawasaki disease. The primary system to monitor in this condition is the cardiovascular system, especially the coronary arteries.

C. Cardiovascular:

This is the correct answer. Kawasaki disease is primarily a vasculitis (inflammation of blood vessels) that affects various blood vessels, including the coronary arteries. The inflammation of the coronary arteries can lead to coronary artery aneurysms and other cardiac complications. Monitoring the cardiovascular system is essential to detect any signs of coronary artery involvement and ensure timely intervention to prevent potential long-term cardiac problems.

D. Integumentary:

The integumentary system (skin) is not the primary focus of Kawasaki disease. While some skin changes can occur during the acute phase of the disease, such as a rash or peeling skin on the hands and feet, these are not the primary concerns. Monitoring the cardiovascular system is critical in Kawasaki disease due to the risk of coronary artery inflammation and potential complications.

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Correct Answer is B

Explanation

In this scenario, the infant has a heart rate of 190/min and a fever of 40°C (104°F). Fever in infants can cause an increase in heart rate, which is a normal physiological response to elevated body temperature. Fever is the body's way of responding to an infection or illness, and it triggers various physiological changes, including an increase in heart rate. This helps the body to circulate blood and deliver immune cells to fight off the infection.
The other options are not accurate or relevant to the infant's current condition:
A. "This is within the expected range for your baby." - A heart rate of 190/min is above the normal expected range for a 2-month-old infant, which is typically between 120 to 160 beats per minute. This response would not address the elevated heart rate and fever.
C. "As your baby begins to fall asleep, his heart rate will decrease." - While heart rate may decrease during sleep, it does not explain the elevated heart rate and fever observed in this situation.
D. "Your baby's heart is beating fast in an attempt to cool down his body." - While tachycardia (fast heart rate) can be associated with increased metabolic demands during fever, the main reason for the increased heart rate in this case is the fever itself, not the body's attempt to cool down. Fever is a response to infection or illness and can cause an increase in heart rate as part of the body's normal immune response.

A. "I will put the enzyme crystals in his applesauce. B. "The enzymes probably won't cause many adverse effects." C. "The enzymes help him digest fat. D. "I will give my son the enzymes between meals.

Correct Answer is D

Explanation

In cystic fibrosis, the pancreas does not secrete enough digestive enzymes, leading to malabsorption of nutrients, especially fats. To help with digestion, pancreatic enzymes are prescribed to be taken with meals and snacks. These enzymes should be given just before or with each meal or snack to aid in the breakdown and absorption of nutrients.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is obtaining vital signs from a 2-month-old infant. The infant's heart rate is 190/min and his temperature is 40° C (104° F). The father asks the nurse why the infant's heart is beating so fast. Which of the following responses by the nurse is appropriate?

Correct Answer is B

Explanation

A nurse is teaching the mother of a 5-year-old child who has cystic fibrosis about pancreatic enzymes. The nurse should understand that further teaching is necessary when the mother states which of the following?

Correct Answer is D

Explanation

A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority?

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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A nurse is teaching the mother of a child who has cystic fibrosis and has a prescription for pancreatic enzymes three times per day. Which of the following statements indicates that the mother understands the teaching?

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