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 C
Explanation
Choice A rationale
This sequence is incorrect because it suggests that blood goes from the lungs to the pulmonary artery, which is not accurate. The pulmonary artery carries deoxygenated blood from the heart to the lungs.
Choice B rationale
This sequence is incorrect because it suggests that blood goes from the pulmonary vein to the lungs, which is not accurate. The pulmonary vein carries oxygenated blood from the lungs to the heart.
Choice C rationale
This sequence correctly describes the direction of blood flow through the heart and lungs. Deoxygenated blood enters the right atrium, goes to the right ventricle, then is sent to the lungs via the pulmonary artery. After picking up oxygen in the lungs, the blood returns to the heart via the pulmonary vein, entering the left atrium, then the left ventricle, from where it is pumped out to the rest of the body.
Choice D rationale
This sequence is incorrect because it suggests that blood goes from the pulmonary vein to the pulmonary artery, which is not accurate. The pulmonary vein carries oxygenated blood from the lungs to the heart, and the pulmonary artery carries deoxygenated blood from the heart to the lungs.
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Allergies to shellfish may indicate iodine allergy, relevant for procedures using iodine-based contrast, like PCI. The client’s shellfish allergy must be reported to the PHCP as a precautionary measure to prevent any allergic reaction.
Choice B rationale: Warm sensations during PCI are a common side effect of the contrast dye used in the procedure. This statement does not indicate an immediate concern requiring PHCP notification as it is a standard patient experience.
Choice C rationale: Anxiety in closed spaces, known as claustrophobia, may affect the client's comfort during PCI but can be managed with sedatives. The PHCP should be aware but it’s not as urgent as taking contraindicated medications.
Choice D rationale: Metformin can lead to lactic acidosis, especially when iodine contrast dye is used during PCI. This condition is serious and may result in adverse interactions. The PHCP must be notified immediately.
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