On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease?
Cracked lips
Desquamation of the skin
Normal appearance
Conjunctival hyperemia
The Correct Answer is D
A. Cracked lips:
Incorrect: While red, cracked lips are part of the mucous membrane changes seen in Kawasaki disease, they are not specific to the acute stage. Mucous membrane changes can occur in both the acute and subacute stages.
B. Desquamation of the skin:
Incorrect: Desquamation, or peeling of the skin, is more characteristic of the subacute or convalescent stages of Kawasaki disease, particularly on the fingers and toes.
C. Normal appearance:
Incorrect: In the acute stage, the child with Kawasaki disease typically exhibits signs of illness, including fever and other clinical manifestations. A "normal appearance" would not be expected in the acute stage.
D. Conjunctival hyperemia.
Explanation: Conjunctival hyperemia, or redness of the eyes, is a common clinical manifestation of the acute stage of Kawasaki disease. Other typical signs and symptoms during this stage include fever, mucous membrane changes (such as red, cracked lips), changes in the extremities, rash, and cervical lymphadenopathy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Shows preferences towards foods
Explanation: Showing preferences towards foods, such as liking some tastes more than others, is a normal developmental behavior in infants. It is not typically a cause for concern.
B. Babbles one-syllable sounds
Explanation:
By the age of 7 months, most infants should be engaging in babbling with repetitive consonant-vowel combinations. If an infant is only producing one-syllable sounds at this age, it might be a potential sign of delayed language development. Further evaluation by a healthcare provider, such as a pediatrician or a speech-language pathologist, may be warranted to assess the child's language and communication skills.
C. Uses a unidextrous grasp
Explanation: A unidextrous grasp, where the infant uses one hand to grasp objects, is a typical developmental milestone at this age. Infants typically begin to show a dominant hand preference later in their development.
D. Has a fear of strangers
Explanation: Fear of strangers, often referred to as "stranger anxiety," is a normal developmental stage that typically emerges around 6 to 9 months of age. It is a sign of social and cognitive development and is not generally a cause for concern.
Correct Answer is C
Explanation
A. "Range-of-motion exercises must be performed every day."
Explanation: While range-of-motion exercises are important for maintaining joint flexibility in juvenile idiopathic arthritis, it is not advisable to perform these exercises during painful exacerbations. The frequency and intensity of exercises may need to be adjusted based on the child's current condition.
B. "Administer additional pain medication before performing range-of-motion exercises."
Explanation: While pain management is important in the care of a child with juvenile idiopathic arthritis, relying solely on pain medication before exercises may not be the most effective approach. Isometric exercises that are less likely to cause pain can be a better option during exacerbations.
C. "Have the child perform simple isometric exercises during this time."
Explanation:
During a painful exacerbation of juvenile idiopathic arthritis, it is important to maintain joint flexibility and prevent joint contractures. Simple isometric exercises that do not involve joint movement can help in maintaining muscle strength and joint flexibility without exacerbating pain. Range-of-motion exercises may be too painful during an exacerbation, but isometric exercises can be less painful and still beneficial.
D. "Avoid all exercise during painful periods."
Explanation: Complete avoidance of exercise during painful periods is not recommended. Maintaining joint flexibility and muscle strength is important for managing juvenile idiopathic arthritis. However, the type and intensity of exercises should be adjusted based on the child's pain level during exacerbations.
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