A nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. Which of the following findings should the nurse expect?
Decreased Heart Rate
Peeling of the soles of the feet
Pain in weight-bearing joints
Fever unresponsive to antipyretics
The Correct Answer is D
A. Decreased heart rate is not typical; children with Kawasaki disease often experience tachycardia.
B. Peeling of the soles of the feet is more commonly observed in the convalescent phase of Kawasaki disease rather than the acute phase.
C. Pain in weight-bearing joints can occur in Kawasaki disease but is not the hallmark symptom during the acute phase.
D. Fever unresponsive to antipyretics is a classic finding in the acute phase of Kawasaki disease, indicating ongoing inflammation and a need for further intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Attach the client's NG tube to low intermittent suction: Suction may be used after lavage for decompression, but during lavage, the focus is on instilling and withdrawing solution manually to clear the stomach of blood or contents.
B. Instill the lavage solution into the client's NG tube in volumes of 500 mL at a time: This volume is excessive and could increase the risk of aspiration or discomfort. Typically, 100–200 mL is used per instillation.
C. Instill chilled lavage solution into the client's NG tube: Chilled solutions are not recommended as they may induce hypothermia and have not been shown to effectively control bleeding. Room-temperature solution is preferred.
D. Use 0.9% sodium chloride for irrigation of the NG tube: Isotonic saline is the recommended solution for gastric lavage, as it helps prevent electrolyte imbalance and irritation.
Correct Answer is A
Explanation
A. Initiating the process to review the medical record is appropriate; clients have the right to access their medical information under HIPAA regulations, and the nurse can assist in starting that process.
B. While there are restricted parts of a medical record, the response lacks a proactive approach to assisting the client in accessing the information they have the right to view.
C. This response is dismissive of the client's request and does not provide an avenue for understanding the medical record better.
D. Although the provider can provide more detailed information about treatment, it does not
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.