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 B
Explanation
Choice A rationale
While it’s important to inquire about an allergy to iodine in a patient who has undergone an angiogram, it’s not typically the priority for assessing and documenting for this patient after the procedure. An allergy to iodine would be more relevant before the procedure, as iodine-based contrast dye is often used during an angiogram.
Choice B rationale
Checking peripheral pulses in the affected leg is typically a priority when caring for a patient who has undergone an angiogram. This is because the procedure involves inserting a catheter into a blood vessel in the leg. Checking the peripheral pulses can help assess for potential complications such as a blood clot or decreased blood flow to the leg.
Choice C rationale
Monitoring for decreased blood pressure is important in a patient who has undergone an angiogram, but it’s not typically the priority for assessing and documenting for this patient after the procedure. While changes in blood pressure can occur after any medical procedure, other assessments such as checking peripheral pulses in the affected leg are typically more directly related to potential complications of an angiogram.
Choice D rationale
Tracking fluid intake is an important part of overall patient care, but it’s not typically the priority for assessing and documenting for a patient who has undergone an angiogram. Other assessments such as checking peripheral pulses in the affected leg are typically more directly related to potential complications of an angiogram.
Correct Answer is A
Explanation
Choice A rationale
A 59-year-old patient with unstable angina who has just returned from a percutaneous coronary intervention (PCI) should be prioritized for assessment. PCI is a procedure to open blocked or narrowed coronary arteries and can lead to complications such as re-occlusion of the artery or bleeding from the catheter insertion site. Furthermore, unstable angina is a condition that can progress to myocardial infarction if not managed effectively.
Choice B rationale
A 56-year-old patient with variant angina due to receive nifedipine (Procardia) requires monitoring, but is not the highest priority. Variant angina is a form of angina that occurs at rest, often with severe pain, but it is usually well-controlled with medications like nifedipine.
Choice C rationale
A 65-year-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about discharge planned for today is a lower priority for assessment. While it’s important to address the patient’s anxiety and provide education about post-discharge care, this patient is not in immediate danger.
Choice D rationale
A 39-year-old patient with pericarditis complaining of sharp, stabbing chest pain requires assessment, but is not the highest priority. Pericarditis is inflammation of the pericardium, the sac-like covering of the heart, and while it can cause severe pain, it is not typically life- threatening.
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