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?

Choice A rationale
Recurring chest pain can be a symptom of a serious condition such as a heart attack, which can occur if a blood clot forms in a vein deep inside the body, breaks off, and travels to the heart.
This is a potential complication of Deep Vein Thrombosis (DVT) and other vascular issues. Therefore, it’s important for the nurse to inquire about recurring chest pain in a patient with a past history of DVT and other vascular issues.
Choice B rationale
A peptic ulcer is a sore that develops on the lining of the stomach, upper small intestine, or lower esophagus. While peptic ulcers can cause discomfort and other symptoms, they are not typically associated with DVT or other vascular issues. Therefore, while it’s always important for the nurse to have a complete understanding of a patient’s health history, inquiring about a peptic ulcer may not be directly relevant to a patient with a past history of DVT and other vascular issues.
Choice C rationale
An aneurysm is a bulge or ballooning in the wall of an artery. Aneurysms can occur in any artery in the body, and they can be life-threatening if they rupture or dissect (tear)3. While aneurysms can be associated with certain vascular diseases, they are not typically associated with DVT3. Therefore, while it’s important for the nurse to be aware of a patient’s complete health history, inquiring about an aneurysm may not be directly relevant to a patient with a past history of DVT.
Choice D rationale
Rheumatoid arthritis is an autoimmune disease that causes inflammation in the joints. While it can cause a variety of symptoms and complications, it is not typically associated with DVT or other vascular issues. Therefore, while it’s always important for the nurse to have a complete understanding of a patient’s health history, inquiring about rheumatoid arthritis may not be directly relevant to a patient with a past history of DVT and other vascular issues.

Choice A rationale
Intermittent claudication and pallor are not typically symptoms of a myocardial infarction. Intermittent claudication, or pain in the legs with exercise, is more commonly associated with peripheral artery disease. Pallor, or paleness, can occur with various conditions but is not a specific sign of myocardial infarction3.
Choice B rationale
Jugular vein distention and dependent edema are not typically symptoms of a myocardial infarction. These signs are more commonly associated with heart failure3.
Choice C rationale
Mid-epigastric pain and heartburn can sometimes be symptoms of a myocardial infarction, particularly in women. However, these symptoms can also occur with many other conditions, including gastrointestinal disorders3.
Choice D rationale
Sweating and cool, clammy skin are common symptoms of a myocardial infarction. These symptoms occur due to the body’s stress response to the decreased blood flow to the heart muscle3.