A nurse is assessing a child with suspected Kawasaki disease. Which finding supports this diagnosis?
Bradycardia and hypotension.
Strawberry tongue and peeling palms.
Petechiae on lower extremities.
Splinter hemorrhages.
The Correct Answer is B
Choice A rationale
Kawasaki disease (KD) is an acute systemic vasculitis often leading to an inflammatory state characterized by fever, conjunctivitis, and rash. The child is expected to be tachycardic and often hypertensive (due to inflammation and hyperdynamic state), or may be hypotensive in later shock, but bradycardia and hypotension are not typical diagnostic findings in the acute phase.
Choice B rationale
The presence of strawberry tongue (erythema and prominent papillae) and peeling (desquamation) of the palms and soles (especially in the subacute phase) are two of the key mucocutaneous findings that fulfill the American Heart Association's diagnostic criteria for Kawasaki disease. This systemic inflammatory response targets epithelial and vascular tissues.
Choice C rationale
Petechiae, small pinpoint hemorrhages, are often associated with conditions like meningococcemia, septicemia, or platelet disorders such as Idiopathic Thrombocytopenic Purpura (ITP). While a non-specific maculopapular rash or perineal desquamation can occur in Kawasaki disease (KD), petechiae are not considered a classic or defining diagnostic criterion.
Choice D rationale
Splinter hemorrhages are small lines of blood under the fingernails or toenails, classically associated with infective endocarditis (microemboli lodging in the nail bed capillaries). While Kawasaki disease can lead to carditis, splinter hemorrhages are not a specific assessment finding that supports the initial diagnosis of this particular systemic vasculitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A high-pitched cry in an infant can be indicative of increased intracranial pressure (ICP) due to stretching of the meninges or irritation of the central nervous system. However, it is a non-specific sign that may also relate to pain or general distress. Normal infant crying is variable, but this specific quality suggests a potentially serious neurological issue.
Choice B rationale
Poor feeding is a non-specific sign of general illness in an infant, reflecting overall malaise or potentially a depressed level of consciousness secondary to increased ICP. Reduced appetite or difficulty sucking/swallowing suggests decreased neurological function or systemic distress but is often less immediately concerning than vital sign changes.
Choice C rationale
Separated cranial sutures (diastasis) and a bulging fontanelle are classic, late-stage physical findings in infants with chronic or acutely escalating ICP. The unfused sutures provide a compensatory mechanism for the expanding volume, but once separated, it signifies a substantial, long-standing pressure increase.
Choice D rationale
Bradycardia (abnormally slow heart rate) is the most concerning part of the Cushing's Triad (hypertension, bradycardia, and irregular respirations), which is a late and critical physiological response to dangerously elevated ICP. The reduced heart rate is a reflex response mediated by the brainstem to maintain cerebral perfusion pressure (CPP).
Correct Answer is ["B","D","E"]
Explanation
Choice A rationale
Risk for infection is a generalized diagnosis and is not specific to the hemodynamic consequences of a large patent ductus arteriosus (PDA). The primary pathophysiology involves a left-to-right shunting of oxygenated blood leading to pulmonary overcirculation and systemic underperfusion, which are more critical issues.
Choice B rationale
A large PDA allows a significant volume of blood to shunt from the aorta (higher pressure) to the pulmonary artery (lower pressure). This diversion of systemic blood volume results in decreased systemic cardiac output and perfusion, leading to compensatory tachycardia and eventual heart failure.
Choice C rationale
Fluid volume deficit is incorrect. The left-to-right shunting in a large PDA causes increased pulmonary blood flow and pressure, leading to pulmonary congestion, which can manifest as fluid volume excess in the lungs and sometimes systemically, not a deficit.
Choice D rationale
The excessive blood flow shunting to the lungs due to a large PDA causes pulmonary overcirculation and pressure increase. This over-perfusion impairs alveolar-capillary gas exchange dynamics, leading to pulmonary edema and ventilation-perfusion mismatch, increasing the risk for impaired gas exchange.
Choice E rationale
The chronic strain on the heart from the increased volume and pressure load due to the large left-to-right shunt requires increased myocardial work. This leads to cardiac muscle fatigue and an inability to meet the body's metabolic demands during exertion, resulting in activity intolerance and poor weight gain.
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