A child cut his hand a few days ago.

Now the area is red, painful, and swollen, and he has a fever.

The nurse could expect which interventions to be part of the treatment plan.

Choice A rationale

Obtaining a full set of vital signs is a crucial part of the secondary assessment, but it follows the primary assessment (ABCs) and the initial rapid assessment of neurological status (AVPU or level of consciousness). The priority immediately after ensuring ABCs is to determine the child's immediate neurological status and responsiveness, which guides subsequent interventions for stabilizing the child.

Choice B rationale

While pain management is extremely important and should be addressed promptly, it is not the immediate priority following the primary ABC assessment. Assessing the level of consciousness (D in the 'ABCDE' trauma/emergency assessment) is the next vital step, as changes in neurological status can indicate immediate life threats like intracranial pressure or hypoxia.

Choice C rationale

Removing the child's clothing (Exposure in the 'ABCDE' approach) is performed to conduct a full physical examination and check for injuries, but it must be done after the immediate life threats (ABCs and initial Disability/LOC) are addressed. This step is also crucial for preventing hypothermia, making temperature regulation important after exposure, but not the first step after ABCs.

Choice D rationale

Assessing the level of consciousness (LOC) is the essential next step after the primary survey (Airway, Breathing, Circulation) in pediatric emergency care, corresponding to the 'D' (Disability) in the ABCDE approach. A rapid assessment, often using the AVPU scale (Alert, Voice, Pain, Unresponsive), provides an immediate gauge of the child's neurological function and helps detect life-threatening issues like hypoxia or severe hypoglycemia.

Choice A rationale

Vigorous exercise is strongly contraindicated in a child with Kawasaki Disease, especially in the acute phase. The primary risk associated with this vasculitis is the potential development of coronary artery aneurysms. Physical exertion increases cardiac workload, which could potentially worsen myocardial ischemia or increase the risk of serious coronary complications.

Choice B rationale

Keeping the child NPO (nothing by mouth) is generally not indicated for routine comfort measures in Kawasaki Disease unless a specific invasive procedure or life-threatening complication, such as severe cardiac failure requiring intubation, is anticipated. Adequate hydration is crucial to prevent dehydration from fever and to maintain fluid balance, which is achieved through oral intake or intravenous fluids.

Choice C rationale

Administering aspirin is a critical part of the medical management for Kawasaki Disease and serves a dual purpose. High-dose aspirin is given for its anti-inflammatory properties to reduce fever and systemic inflammation. Later, low-dose aspirin is continued for its anti-platelet effects to prevent the formation of blood clots, especially in the setting of coronary artery aneurysms.

Choice D rationale

Splinting extremities for contractures is not a typical intervention for the acute phase of Kawasaki Disease. Joint pain (arthralgia) and stiffness may occur, but contractures are not a primary or immediate complication. To promote comfort, the nurse should instead handle the extremities gently and provide passive range of motion to prevent further joint stiffness.