A nurse is caring for a child who has Kawasaki disease.
Which of the following systems should the nurse monitor in response to this diagnosis?
Gastrointestinal
Integumentary
Respiratory
Cardiovascular
The Correct Answer is D
Choice A rationale
While gastrointestinal symptoms can occur in Kawasaki disease, such as diarrhea, vomiting, and abdominal pain, the primary system affected is not the gastrointestinal system.
Choice B rationale
Although Kawasaki disease can cause symptoms such as a rash and changes in the lips and oral cavity, which are related to the integumentary system, the primary system affected is not the integumentary system.
Choice C rationale
Respiratory symptoms are not typically a primary concern in Kawasaki disease. While a child with Kawasaki disease may have some respiratory symptoms such as a cough and runny nose, these are not the main focus of monitoring.
Choice D rationale
Kawasaki disease is a systemic vasculitis that predominantly affects the cardiovascular system. It is the leading cause of acquired heart disease in children. Therefore, monitoring the cardiovascular system is crucial in managing a child with Kawasaki disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Maternal bradycardia refers to a slower than normal heart rate in the mother. While it can affect the baby’s health, it doesn’t cause late decelerations on the fetal monitor.
Choice B rationale
Late decelerations are caused by uteroplacental insufficiency, which is a decrease in the blood flow to the placenta that reduces the amount of oxygen and nutrients transferred to the fetus. This is why the nurse would interpret late decelerations as indicating uteroplacental insufficiency.
Choice C rationale
Umbilical cord compression can cause variable decelerations, not late decelerations. Variable decelerations are abrupt decreases in the fetal heart rate, typically associated with contractions, and they vary in onset, depth, and duration.
Choice D rationale
Fetal head compression typically causes early decelerations, not late decelerations. Early decelerations are a mirror image of the contraction and are generally not a concern.
Correct Answer is B
Explanation
Choice A rationale
Constipation is not typically associated with a sickle cell crisis. While it can occur due to dehydration, which can trigger a sickle cell crisis, it is not a primary symptom.
Choice B rationale
Pain is the most common symptom of a sickle cell crisis. When sickle-shaped cells block blood flow in the small blood vessels, it can cause severe pain. This pain can occur anywhere in the body, but it most often occurs in the chest, arms, and legs.
Choice C rationale
Bradycardia is not typically a symptom of a sickle cell crisis. Sickle cell crisis primarily affects the blood vessels and does not directly cause a slow heart rate.
Choice D rationale
While a high fever can occur in individuals with sickle cell disease, especially if there is an underlying infection, it is not a primary symptom of a sickle cell crisis.
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