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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Prolonged PR intervals occur with first-degree AV block, not typically with pericarditis.
Choice B rationale
Clubbing of the fingers is a loss of the normal angle between the base of the nail and the skin. This finding can be found in endocarditis, congenital defects, and/or prolonged oxygen deficiency. It is not a typical manifestation of pericarditis.
Choice C rationale
Widened pulse pressure occurs with valvular heart disease, not typically with pericarditis.
Choice D rationale
Pulsus paradoxus is a sign of cardiac tamponade, a serious complication of pericarditis. As the compression of the heart increases, decreased left atrial filling decreases cardiac output.
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.
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