A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?

Monitor the child's cardiac status.

Give scheduled doses of acetaminophen every 6 hr.

Provide stimulation with children of the same age in the play room.

Administer antibiotics via intermittent IV bolus for 24 hr.

Answer and Explanation

The Correct Answer is A

A.   Kawasaki disease involves inflammation of the blood vessels and can lead to serious cardiac complications, including coronary artery aneurysms. Monitoring cardiac status is essential to detect and manage these risks.
B.   While managing fever is a part of treating Kawasaki disease, acetaminophen is typically used as needed rather than on a strict schedule unless fever is persistent.
C.   During the acute phase of Kawasaki disease, children often feel very irritable and unwell; large group activities may be overwhelming and inappropriate.
D.   Kawasaki disease is not caused by a bacterial infection, and antibiotics are not part of the treatment. Instead, treatment usually involves high-dose aspirin and intravenous immunoglobulin.

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Correct Answer is B

Explanation

A. Directing statements to the interpreter rather than the client can create a communication barrier and undermine the client's autonomy and involvement in the conversation.
B. Speaking in a normal voice at a natural pace allows the interpreter to accurately convey the message to the client without feeling rushed or overwhelmed, facilitating effective communication.
C. Pausing in the middle of sentences can disrupt the flow of communication and make it difficult for the interpreter to accurately translate the message.
D. While gestures can complement verbal communication, relying solely on gestures may lead to misinterpretation or misunderstanding, especially if cultural differences exist between the nurse, client, and interpreter.

A. A client who has Clostridium difficile and a temperature of 38.6° C (101.5° F) B. A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10 C. A client who has left shoulder pain and S-T elevation on a 12-lead ECG D. A client who has orthostatic hypotension and 4+ pitting edema in the lower extremities

Correct Answer is C

Explanation

A. While a temperature elevation in a client with Clostridium difficile requires assessment, it is not as urgent as potential cardiac ischemia.
B. Pain assessment in a client with a femur fracture is important but does not take priority over potential cardiac issues.
C. Left shoulder pain with S-T elevation on an ECG can indicate myocardial infarction (MI), a life-threatening condition requiring immediate assessment and intervention.
D. Orthostatic hypotension and pitting edema, while concerning, do not indicate an acute, life-threatening condition that requires immediate assessment in this scenario.

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A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter?

Correct Answer is B

Explanation

A nurse in the emergency department is receiving report on a group of clients. Which of the following clients should the nurse assess first?

Correct Answer is C

Explanation

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