When caring for the child with Kawasaki disease, the nurse should understand what principle of care?

The correct answer is Choice C: Measure abdominal girth.

Choice A rationale:

Taking vital signs, including blood pressure, is important in assessing the overall health status of a child, but it might not provide specific information about a probable intussusception. Blood pressure is not typically affected in a way that directly relates to intussusception.

Choice B rationale:

Auscultating for bowel sounds is an important assessment technique in various gastrointestinal conditions, but it may not be the most appropriate immediate action when dealing with a probable intussusception. While bowel sounds might be diminished or absent in intussusception, the priority should be on assessing other signs and symptoms.

Choice C rationale:

Measuring abdominal girth is an essential nursing action when a child with a probable intussusception has a normal, brown stool. Intussusception is the telescoping of one segment of the intestine into another, often leading to bowel obstruction. Abdominal distension or girth measurement can provide valuable information about the progression of the condition and potential obstruction.

Choice D rationale:

Notifying the practitioner is an important step, but it might not be the most immediate action required. Assessing and monitoring the child's condition should be the initial response to gather more information before notifying the practitioner.

The correct answer is choice D. Epiglottitis.

Choice A rationale:

Laryngotracheobronchitis (LTB) is a viral infection commonly known as "croup." While it can cause airway inflammation and respiratory distress, it is usually not considered a medical emergency. LTB is characterized by barking cough, stridor, and hoarseness. It typically responds well to supportive care, humidity, and sometimes oral corticosteroids.

Choice B rationale:

Spasmodic croup is another type of viral croup, often triggered by allergies or irritants. It is characterized by sudden onset of symptoms, usually at night, including stridor and a barking cough. While it can be distressing, it is generally not considered a medical emergency. It usually responds to humidity and sometimes oral corticosteroids.

Choice C rationale:

Laryngitis involves inflammation of the larynx and is often caused by viral infections or excessive voice use. While it can lead to hoarseness and voice changes, it does not typically cause severe respiratory distress and is not considered a medical emergency. Resting the voice and staying hydrated are common interventions.

Choice D rationale:

Epiglottitis is a potentially life-threatening condition that causes inflammation of the epiglottis, a flap of tissue that prevents food from entering the windpipe during swallowing. It can rapidly progress to airway obstruction and respiratory failure. Children with epiglottitis often assume a "tripod" position, leaning forward to maintain an open airway. Immediate medical intervention, including securing the airway and administering antibiotics, is crucial.