A nurse at a community clinic is caring for a school-aged child.
The client is at risk for
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"D"}
Rationale for correct answers
Kawasaki disease is an acute vasculitis of unknown etiology, most likely triggered by an autoimmune inflammatory process. It primarily affects children under 5 but can occur in school-aged children. Clinical features include prolonged fever (>5 days), mucocutaneous inflammation (strawberry tongue, cracked lips), conjunctivitis, rash, and cervical lymphadenopathy. Tachycardia (HR >100/min) and tachypnea (RR >20/min) may reflect systemic inflammation. Risk of coronary artery aneurysm necessitates early diagnosis and IVIG treatment. Lab findings often include:
- Elevated ESR/CRP
- Thrombocytosis (>450,000/mm³ in subacute phase)
- Sterile pyuria
- Mild transaminitis
Rationale for incorrect Response 1 options
A. Acute rheumatic fever follows untreated Group A Streptococcus pharyngitis and presents with migratory arthritis, carditis, and chorea—not mucocutaneous signs or persistent fever without sore throat.
B. Toxic epidermal necrolysis is a severe drug reaction with widespread epidermal detachment, not associated with systemic vasculitis or cardiovascular risk.
C. Hemolytic uremic syndrome presents with bloody diarrhea, anemia, and renal failure—none of which are noted here.
Rationale for incorrect Response 2 options
A. Group A beta-hemolytic streptococcus infection causes rheumatic fever and glomerulonephritis, not Kawasaki disease.
B. Adverse drug reaction may cause TEN or Stevens-Johnson syndrome, but not Kawasaki’s vasculitis.
C. Shiga toxin-producing E. coli causes HUS, not systemic vasculitis or mucocutaneous inflammation.
Take-home points
- Kawasaki disease is a pediatric vasculitis with risk of coronary artery aneurysm.
- Diagnosis is clinical; fever >5 days plus ≥4 mucocutaneous criteria.
- Differentiate from HUS, rheumatic fever, and drug reactions based on systemic and mucocutaneous findings.
- Early IVIG and aspirin reduce cardiac complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Acting in the best interest of the client is most closely aligned with the principle of beneficence. This ethical principle obligates the nurse to perform actions that benefit the client and promote their well-being. It is a core tenet of nursing ethics, but it is distinct from the concept of accountability, which focuses on responsibility for one's actions.
Choice B rationale
Accountability is the ethical principle that requires nurses to be answerable for their own actions and professional conduct. It involves taking ownership of one's decisions and their outcomes, both positive and negative. It is a fundamental aspect of professional practice, ensuring nurses can be trusted to act responsibly and ethically.
Choice C rationale
Respecting professional obligations is part of fidelity. Fidelity is the principle of keeping promises and commitments, including those made to the client and professional obligations. While related to ethical conduct, it is a separate principle from accountability, which specifically addresses the responsibility for one's actions.
Choice D rationale
The obligation to respect client privacy is a core component of confidentiality. This ethical principle dictates that nurses must protect the personal and health information of their clients. It is a legal and ethical duty that is separate from the concept of accountability, which focuses on being answerable for one's actions.
Correct Answer is B
Explanation
Choice A rationale
Scheduling appointments for physical therapy services is an example of the coordinator role. In this capacity, the nurse organizes and arranges various aspects of the client's care plan, ensuring that all necessary services are in place and accessible. This role is focused on logistical management, not on mediating between parties.
Choice B rationale
Discussing payment options with various pharmacies is an example of the negotiator role. In this role, the nurse mediates between the client and a third party, such as a pharmacy, to find a mutually beneficial solution. The nurse advocates for the client to ensure access to affordable and necessary medications.
Choice C rationale
Reporting safety concerns to the home health agency is an example of the advocate role. Here, the nurse is acting on behalf of the client to ensure their safety and well-being in the home environment. The nurse's actions are focused on protecting the client and communicating concerns to the appropriate party.
Choice D rationale
Providing social services with a list of needed referrals is an example of the referral agent role. In this capacity, the nurse connects the client with appropriate resources and services, such as social workers or community support groups, to address their non-medical needs. This role is about connecting, not negotiating.
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