A nurse is caring for a 6-year-old child in an emergency department.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition: Kawasaki Disease

Kawasaki disease is a systemic vasculitis that primarily affects children under the age of 5 but can occur in older children. It presents with prolonged fever (lasting more than 5 days), conjunctival injection (red eyes without exudate), mucosal inflammation (strawberry tongue, red lips), maculopapular rash, and extremity changes (edema and peeling skin on hands and feet). Elevated inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), high WBC count, and thrombocytosis (elevated platelets) are consistent with Kawasaki disease. If untreated, it can lead to coronary artery aneurysms.

Actions to Take:

Plan to administer high dose of aspirin:

High-dose aspirin is given to reduce inflammation and prevent thrombosis in coronary arteries, as Kawasaki disease increases the risk of coronary artery aneurysms.

Assess for neurological changes:

Neurological changes, such as irritability, can indicate aseptic meningitis or other central nervous system involvement, which can occur in Kawasaki disease.

Parameters to Monitor:

Daily weights:

Monitoring daily weights is essential to assess for fluid retention or overload, as Kawasaki disease can cause myocarditis and cardiac dysfunction.

Reports of chest pain or pressure:

Monitoring for chest pain or pressure is crucial to detect early signs of myocardial ischemia or coronary artery involvement, which are potential complications of Kawasaki disease.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Tympanic thermometers are not recommended for newborns because the ear canal is difficult to assess accurately in this age group.

B. Oral temperatures are not recommended for newborns due to the difficulty in ensuring accuracy.

C. The axillary site is the recommended method for obtaining a newborn's temperature. It is safe and non-invasive.

D. Rectal temperatures are accurate but are invasive and may cause discomfort or injury. It should only be used if other methods are not feasible.

A. "I know that I will be reunited with my child someday." B. "I am unable to feel any joy since my child died." C. "I feel guilty because my child died." D. "I am angry that my child died."

Correct Answer is B

Explanation

A. Belief in being reunited with the child is a common and healthy coping mechanism.

B. Inability to experience joy (anhedonia) is a key symptom of major depressive disorder and warrants further assessment.

C. Feeling guilty is a normal part of grief but does not necessarily indicate major depression.

D. Anger is a normal stage of grief and does not typically indicate a disorder unless prolonged or extreme.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is obtaining the temperature of a newborn. Which of the following sites should the nurse use?

Correct Answer is C

Explanation

A nurse is assessing the grief response of a client whose child died 6 months ago. Which of the following client statements should the nurse report to the provider as an indication of major depressive disorder?

Correct Answer is B

Explanation

A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?

A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement, and the nurse offers a bed pan. The client states, "I've always used the bathroom." Which of the following responses should the nurse make?

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