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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A.Factor X is a clotting factor involved in the coagulation cascade. It is not directly related to preventing infections. While clotting factors are essential for hemostasis, they do not play a role in infection prevention.
B. Steroids can suppress the immune response, making the child more susceptible to infections. Therefore, they are not specifically administered to prevent infections
C. In a child with a sickle cell crisis who is hospitalized, preventing infections is crucial due to the increased risk of infections in this condition. Administering immunizations that the patient is scheduled for can help prevent certain infections.
Children with sickle cell disease are at a higher risk of bacterial infections, especially from encapsulated organisms like Streptococcus pneumoniae and Haemophilus influenzae. Vaccines can help protect against these pathogens and reduce the risk of serious infections.
Some of the recommended immunizations for children with sickle cell disease include:
Pneumococcal vaccine: This helps protect against infections caused by Streptococcus pneumoniae, which can cause severe respiratory and bloodstream infections.
Haemophilus influenzae type B (Hib) vaccine: This protects against infections caused by Haemophilus influenzae type B, which can lead to serious illnesses like pneumonia and meningitis.
Meningococcal vaccine: This protects against Neisseria meningitidis, which can cause meningitis and bloodstream infections.
Influenza vaccine: This annual vaccine helps protect against seasonal flu, which can be severe in children with sickle cell disease.
Administering these vaccines according to the recommended schedule helps provide protection against certain infections and can improve outcomes for children with sickle cell disease during hospitalization and beyond. The other options, Factor X, steroids, and PCA morphine, are not specific measures for preventing infections in a child with sickle cell crisis.
D.PCA (patient-controlled analgesia) morphine is used for pain management during a sickle cell crisis. It does not directly prevent infections.
Correct Answer is D
Explanation
When caring for a child with acute appendicitis, the nurse should anticipate an elevated white blood cell count (WBC) in the laboratory values. A high WBC count is a common finding in acute appendicitis, as it indicates an inflammatory response and infection in the body. The body's immune system responds to the inflammation caused by the infected appendix, leading to an increase in WBCs to fight off the infection.
The other options are not necessarily specific to acute appendicitis:
A. RBC 4.2 million/mm³: The red blood cell count (RBC) measures the number of red blood cells in the bloodstream. This value may be within the normal range, but it is not the primary marker for diagnosing or monitoring acute appendicitis.
B. Lymphocytes 3,000/mm3: Lymphocytes are a type of white blood cell involved in the body's immune response. While changes in lymphocyte levels can occur during inflammation, it is not the primary marker for diagnosing or monitoring acute appendicitis.
C. Neutrophils 3.000/mm³: Neutrophils are a type of white blood cell that increases in response to infection and inflammation. However, the absolute neutrophil count is not as relevant as the overall WBC count in determining the presence and severity of acute appendicitis.
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