A nurse is assessing a client who has a blood glucose level of 265 mg/dL (74 to 106 mg/dL). Which of the following clinical manifestations is associated with this finding?

Rationale for correct choices

• Kawasaki disease: The child presents with prolonged fever, conjunctival injection without exudate, inflamed oral mucosa, cracked lips, maculopapular rash, and edema with peeling of hands and feet. Laboratory findings include elevated WBC, CRP, ESR, and platelets, consistent with systemic inflammation. These clinical and lab features strongly indicate Kawasaki disease, a medium-vessel vasculitis primarily affecting children under 5–6 years of age.

• Assess for neurological changes: Neurological assessment is important because Kawasaki disease can involve the central nervous system, leading to irritability, lethargy, or aseptic meningitis. Continuous monitoring of neurological status helps identify complications early and guides supportive interventions.

• Plan to administer high dose of aspirin: High-dose aspirin is a standard treatment in the acute phase of Kawasaki disease to reduce inflammation and prevent coronary artery complications. It helps mitigate fever and vascular inflammation. This intervention is central to managing the inflammatory process and reducing the risk of long-term cardiac sequelae.

• Reports of chest pain or pressure: Monitoring for chest pain or pressure is essential because Kawasaki disease can lead to coronary artery aneurysms or myocardial ischemia. These symptoms may indicate cardiac involvement requiring immediate attention. Ongoing assessment helps detect early signs of cardiovascular complications, which are the most serious consequences of the disease.

• Daily weights: Daily weights help monitor fluid balance and detect edema, which may develop as part of systemic inflammation or as a response to treatment. Tracking weight changes assists in identifying fluid retention or loss, guiding interventions such as fluid management. Weight monitoring provides an objective measure of the child’s overall clinical status.

Rationale for incorrect choices

• Reyes syndrome: Reye’s syndrome is associated with post-viral illness and aspirin use, presenting with hepatic dysfunction and encephalopathy. The child’s symptoms of conjunctivitis, rash, and extremity changes do not align with Reye’s syndrome. Liver function tests and neurological deterioration would be more prominent, making this diagnosis unlikely.

• Varicella: Varicella (chickenpox) typically presents with vesicular lesions in different stages of healing, starting on the trunk and face. This child has maculopapular rash, not vesicular lesions, and systemic signs such as conjunctival injection and oral mucosa changes are not typical of varicella. The lab findings further support an inflammatory rather than viral etiology.

• Rheumatic fever: Rheumatic fever usually develops after untreated streptococcal pharyngitis and affects joints, heart valves, skin, and CNS (Sydenham chorea). This child’s current symptoms of rash, edema, conjunctivitis, and mucous membrane involvement do not fit the classic Jones criteria for rheumatic fever. Cardiac murmurs or migratory polyarthritis are absent, making this unlikely.

• Restrict fluid and salt intake: Fluid restriction is not a standard intervention in Kawasaki disease unless cardiac complications arise. Restricting fluids prematurely could risk dehydration and worsen systemic inflammation. Immediate priority is anti-inflammatory therapy and monitoring for cardiovascular involvement.

• Provide soft food: Providing soft food addresses oral discomfort but does not treat the underlying inflammatory vasculitis. While it may improve comfort, it does not impact disease progression or prevent cardiac complications, making it a lower-priority intervention.

• Implement airborne precautions: Airborne precautions are indicated for infections such as measles, varicella, or tuberculosis. Kawasaki disease is not contagious, so airborne precautions are unnecessary. Standard precautions suffice, allowing focus on managing inflammation and monitoring cardiac status.

• Prolonged bleeding time: Bleeding time is not a primary concern in Kawasaki disease and does not guide treatment or monitoring. The child’s labs indicate thrombocytosis rather than coagulopathy. This parameter is more relevant for platelet disorders or anticoagulant therapy.

• Lesion bruising: Bruising is not a feature of Kawasaki disease; the child’s rash is maculopapular, not hemorrhagic. Lesion bruising would suggest a hematologic or coagulation disorder, which is not indicated in this case.

• Chorea: Chorea is a hallmark of Sydenham chorea, a manifestation of rheumatic fever. The child exhibits irritability but not involuntary movements. Absence of chorea helps differentiate Kawasaki disease from post-streptococcal neurological complications.

A. Providing a verbal report of the client's status to a paramedic performing the transfer: Sharing relevant health information with personnel directly involved in the client’s care is appropriate and necessary for continuity of care. This does not constitute a breach of confidentiality because it is directly related to the client’s treatment and transfer.

B. Faxing the client's medical records to the long-term care facility: Sending medical records to the receiving facility ensures that the client’s care can continue without interruption. As long as the transmission is secure and the information is limited to what is necessary, this is an appropriate and legally permissible action.

C. Discussing the client's reaction to the transfer with another staff nurse: Sharing personal information about the client’s emotional response outside of a care-related context is not necessary for treatment or transfer and constitutes a breach of confidentiality. Such discussions should be avoided to protect the client’s privacy.

D. Leaving a phone message for the provider regarding the status of the client's transfer: Communicating with the provider about the client’s care is appropriate. Leaving a message regarding transfer status is relevant to the client’s treatment and does not violate confidentiality, provided the information is limited to necessary clinical details.