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

The correct answers are choices A and E: Institute cluster care to encourage adequate rest and Place on noninvasive oxygen monitoring.

Choice A rationale:

Institute cluster care to encourage adequate rest. This is a correct choice. Cluster care involves grouping nursing interventions together to minimize disruptions to the child's rest. Adequate rest is crucial for the healing process in infants with respiratory syncytial virus (RSV) bronchiolitis.

Choice B rationale:

Administer cough syrup. This choice is incorrect for RSV bronchiolitis. Cough syrup is not recommended for infants with bronchiolitis. RSV primarily affects the lower respiratory tract and can cause airway inflammation, making cough syrup potentially ineffective and unnecessary.

Choice C rationale:

Administer antibiotics. This choice is incorrect for RSV bronchiolitis. RSV is a viral infection, and antibiotics are ineffective against viruses. Antibiotics should only be used when there is a bacterial infection or a clear indication.

Choice D rationale:

Encourage infant to drink 8 ounces of formula every 4 hours. This choice is not the best approach for managing RSV bronchiolitis. Infants with RSV may experience decreased appetite due to respiratory distress. Smaller, more frequent feedings are often recommended to prevent overfeeding and aspiration.

Choice E rationale:

Place on noninvasive oxygen monitoring. This is a correct choice. RSV bronchiolitis can cause respiratory distress and compromise oxygenation. Noninvasive oxygen monitoring helps assess the child's oxygen levels and aids in determining the need for supplemental oxygen therapy.

The correct answer is choice B. First stage.

Choice A rationale:

There is no fourth stage of Lyme disease. Lyme disease typically progresses through three stages: early localized, early disseminated, and late disseminated. The symptoms mentioned in the question are more indicative of earlier stages of the disease.

Choice B rationale:

The child is likely exhibiting symptoms of the first stage of Lyme disease, known as early localized Lyme disease. This stage is characterized by the appearance of small annular (circular) lesions known as erythema migrans. These lesions are often red and have a clear center, resembling a "bull's-eye" pattern. This stage occurs within days to weeks after a tick bite and is usually accompanied by flu-like symptoms.

Choice C rationale:

There is no third stage of Lyme disease. The third stage is considered the late disseminated stage, which occurs months to years after the initial infection. It typically involves more severe symptoms, such as arthritis, neurological issues, and cardiac abnormalities.

Choice D rationale:

There is no second stage of Lyme disease. The second stage is the early disseminated stage, which occurs weeks to a few months after the tick bite. It involves the spread of the bacteria to other parts of the body, leading to symptoms such as multiple erythema migrans lesions, flu-like symptoms, fatigue, and muscle and joint pain.