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
An oxygen saturation of 88.
Choice B rationale
Bounding peripheral pulses are a classic finding in Patent Ductus Arteriosus (PDA) due to the wide pulse pressure, which results from the run-off of blood from the aorta back into the pulmonary artery during diastole. This finding supports the diagnosis but is not typically the most concerning indicator of impending decompensation.
Choice C rationale
The machinery-like murmur is the pathognomonic sign of a Patent Ductus Arteriosus, caused by continuous blood flow from the high-pressure aorta to the low-pressure pulmonary artery. This is an expected diagnostic finding for PDA, confirming the presence of the defect, but it is not an indicator of acute distress.
Choice D rationale
A respiratory rate of 60 breaths per minute in a 2-month-old infant is a significant indicator of tachypnea and potential respiratory distress, likely due to pulmonary overcirculation and the resulting congestive heart failure (CHF) caused by the PDA. This elevated rate signals a critical effort to compensate for decreased pulmonary compliance and is the most immediate concern.
Correct Answer is ["B","C","E","F"]
Explanation
Choice A rationale
Restricting fluids is generally contraindicated in meningitis unless there is documented syndrome of inappropriate antidiuretic hormone (SIADH) or severe, life-threatening cerebral edema. Maintaining adequate hydration is crucial to prevent dehydration and support systemic circulation, especially since fever can increase fluid loss.
Choice B rationale
Monitoring for signs of increased intracranial pressure (ICP) is paramount because meningeal inflammation can lead to cerebral edema and impaired CSF reabsorption. Signs like changes in level of consciousness, bradycardia, and hypertension (Cushing's triad) require immediate intervention to prevent brain herniation.
Choice C rationale
Administering acetaminophen (or ibuprofen) is appropriate for controlling the systemic symptoms of fever (pyrexia) and managing headache/body pain associated with meningeal irritation. Effective fever control reduces metabolic demands and can decrease the risk of febrile seizures.
Choice D rationale
Administering IV antibiotics immediately is the standard for bacterial meningitis to prevent morbidity and mortality, but viral meningitis is typically self-limiting and managed with supportive care; thus, empirical antibiotics are not indicated if the viral etiology is confirmed or highly suspected.
Choice E rationale
Encouraging rest and hydration is the cornerstone of supportive care for viral meningitis. Rest reduces cerebral metabolic demand and prevents overexertion, while hydration helps combat fluid losses from fever and vomiting and supports overall recovery.
Choice F rationale
Providing a quiet, dimly lit environment helps reduce noxious stimuli that can exacerbate common symptoms like headache and photophobia (light sensitivity), which are caused by meningeal inflammation and irritation of cranial nerves, thus promoting comfort and rest.
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