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 D
Explanation
A. Brachial artery:
Incorrect: The brachial artery is commonly used for measuring blood pressure in infants but not for assessing heart rate.
B. Radial artery:
Incorrect: The radial artery is not typically used for assessing an infant's heart rate, especially in the clinical setting.
C. Carotid artery:
Incorrect: The carotid artery is not commonly used for assessing an infant's heart rate. It is more commonly used in adults, but in infants, the apex of the heart is the preferred site.
D. Apex of the heart.
Correct Answer: The apex of the heart is the most accurate site for counting an infant's heart rate. It is located at the point of maximum impulse (PMI), which is usually at the fifth intercostal space in the mid-clavicular line.
Correct Answer is B
Explanation
A. "I will have my child wear soft fabric clothing under the brace."
Explanation: Wearing soft fabric clothing under the brace can enhance comfort and reduce the risk of irritation. This is a suitable practice.
B. "I need to apply lotion under the brace to prevent skin breakdown."
Explanation:
Applying lotion under the brace may lead to moisture accumulation and skin breakdown. It is generally recommended to keep the skin clean and dry under the brace to prevent irritation and pressure sores. Lotions or creams can contribute to moisture, potentially causing skin problems.
C. "I need to avoid the use of powder because it will cake under the brace."
Explanation: Powder can accumulate and cake under the brace, leading to skin issues. This statement is correct, emphasizing the importance of avoiding the use of powder.
D. "I will encourage my child to perform prescribed exercises."
Explanation: Encouraging the child to perform prescribed exercises is essential for maintaining flexibility and strength. This statement reflects a positive and supportive approach to managing scoliosis.
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