As a nurse preparing for the admission of a child diagnosed with acute-stage Kawasaki disease, what clinical manifestation of the acute stage of the disease should be anticipated during the assessment?
Cracked lips.
Conjunctival hyperemia.
A normal appearance.
Desquamation of the skin.
The Correct Answer is B
Choice A rationale
Cracked lips are a symptom of Kawasaki disease, but they are more commonly associated with the subacute phase of the disease, not the acute phase.
Choice B rationale
Conjunctival hyperemia, or redness of the whites of the eyes, is a common symptom in the acute phase of Kawasaki disease. It typically presents as bilateral, non-exudative conjunctival injection, primarily in the bulbar conjunctivae.
Choice C rationale
A normal appearance is not typically seen in the acute phase of Kawasaki disease, which is characterized by a high fever and at least four of the five main symptoms, including conjunctival hyperemia.
Choice D rationale
Desquamation of the skin, or peeling, is a symptom of Kawasaki disease, but it typically occurs in the subacute phase, not the acute phase.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Elevating the leg above the level of the heart would not be beneficial in this case. This action would actually reduce blood flow to the leg, which is already compromised due to the arterial occlusion.
Choice B rationale
Exercising the leg would increase the oxygen demand of the tissues in the leg, which could exacerbate the problem. The tissues in the leg are already deprived of oxygen due to the arterial occlusion.
Choice C rationale
Applying a compression stocking to the leg would not be beneficial in this case. This action would further compromise blood flow to the leg, which is already reduced due to the arterial occlusion.
Choice D rationale
Keeping the patient in bed in the supine position is the correct action. This position will decrease the oxygen demand of the tissues in the leg and minimize ischemic damage until circulation can be restored.
Correct Answer is B
Explanation
Choice A rationale
While reducing anxiety and relieving pain are important aspects of care, they are not the primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level. These findings indicate myocardial injury, which requires interventions to improve myocardial oxygenation and reduce cardiac workload.
Choice B rationale
The primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level is to improve myocardial oxygenation and reduce cardiac workload. This can be achieved through medications, oxygen therapy, and bed rest.
Choice C rationale
Eliminating family stressors and providing a calm environment can contribute to reducing anxiety and promoting relaxation, but it is not the primary goal in this situation.
Choice D rationale
Starting the client on a low-sodium diet and decreasing fluid intake are interventions for managing heart failure, not for an acute myocardial injury.
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