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 C: "Salt restriction."

Choice A rationale:

The requirement of a high protein diet is not typically indicated for a child with nephrosis. Nephrosis, a condition characterized by excessive protein in the urine, indicates a need to reduce protein intake to alleviate kidney stress and proteinuria.

Choice B rationale:

A low fat diet is not a specific requirement for a child with nephrosis. The focus in nephrosis is primarily on protein and salt intake rather than fat content.

Choice C rationale:

Salt restriction is the correct requirement for a child with nephrosis. Nephrosis often leads to fluid retention and edema due to impaired kidney function. Restricting salt intake helps to reduce fluid retention and manage blood pressure.

Choice D rationale:

A high carbohydrate diet is not commonly prescribed for a child with nephrosis. While carbohydrates are a source of energy, they are not a primary consideration in managing nephrosis. The emphasis is more on protein and salt intake.