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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

A. Perform chest percussion and vibration. Chest percussion and vibration help loosen and mobilize mucus in the airways, which is essential for clients with productive cough and a history of smoking-related respiratory issues. This intervention facilitates effective expectoration and improves breathing.

B. Place the client in a supine position. Placing the client in a supine position can worsen shortness of breath, especially in individuals with respiratory distress. The client should be positioned upright or in a high-Fowler's position to facilitate lung expansion.

C. Instruct the client to perform diaphragmatic breathing. Diaphragmatic breathing helps improve lung expansion, reduce the work of breathing, and promote relaxation. This technique is particularly useful for clients with an irregular breathing pattern and anxiety.

D. Assess the client's breath sounds. Continuous assessment of breath sounds is critical to monitor the effectiveness of interventions, such as oxygen therapy and nebulization, and to detect any worsening of respiratory status.

E. Restrict the client's fluid intake. Fluid intake should not be restricted unless contraindicated, as hydration helps thin mucus, making it easier to expectorate. This is particularly important for clients with a productive cough.

F. Increase oxygen flow rate to 4 L/min. Increasing the oxygen flow rate beyond 2 L/min requires caution in clients with chronic obstructive pulmonary disease (COPD) or similar conditions, as higher oxygen levels can suppress their respiratory drive. Oxygen therapy should be titrated carefully based on the provider's prescription and monitoring of oxygen saturation.

A. A client who has obsessive-compulsive disorder and is upset about a change in daily routine B. A client who has depressive disorder and requires assistance with ADLs C. A client who is taking clozapine to treat schizophrenia and reports a sore throat D. A client who has narcissistic personality disorder and is mocking others during group therapy

Correct Answer is C

Explanation

A. A client upset about a change in routine does not present an immediate threat to their health.

B. Assistance with ADLs is important but not urgent compared to a possible adverse drug reaction.

C. A sore throat in a client taking clozapine may indicate agranulocytosis, a potentially life-threatening condition that requires immediate evaluation.

D. Mocking others is disruptive but not a priority over a potential medical emergency.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the emergency department. Exhibits Which of the following interventions should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first?

Correct Answer is C

Explanation

A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile. Which of the following infection control precautions should the nurse take?

A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?

A nurse is assessing the coping strategies of a client who has recently retired. Which of the following statements by the client indicates that the client is using compensation as a defense mechanism?

A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?

A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?

A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?

A nurse is teaching dietary guidelines to a client who has celiac disease. Which of the following food choices is appropriate for this client?