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 C

Explanation

A. Contractions lasting 80 seconds, while prolonged, may occur in active labor and do not necessarily indicate a complication requiring immediate provider notification.
B. Early decelerations in the fetal heart rate are typically benign and are not typically concerning unless they are persistent or associated with other signs of fetal distress.
C. An FHR baseline of 170/min is above the normal range and may indicate fetal distress or other complications requiring further evaluation and possible intervention, necessitating prompt provider notification.
D. A temperature of 37.4°C (99.3°F) is within the normal range and does not typically require immediate provider notification unless accompanied by other concerning symptoms.

A. Monitor the client's vital signs every 12 hr. B. Inspect the client's mouth every 8 hr. C. Provide fresh fruit with the client's meals. D. Rotate health care staff caring for the client.

Correct Answer is B

Explanation

A. Monitoring vital signs every 12 hours is a standard nursing intervention but may not specifically address the needs of a client with immunosuppression.
B. Inspecting the client's mouth every 8 hours can help in early detection of mouth sores or infections, which are common in immunosuppressed individuals.
C. Providing fresh fruit with meals may not be appropriate for a client with immunosuppression, as fresh fruits can harbor pathogens that pose a risk of infection.
D. Rotating healthcare staff caring for the client helps increases the risk of introducing pathogens to the client. This increases the risk of infection in the immunosuppressed client.

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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

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