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 A
Explanation
Choice A rationale
The nurse should reassure the patient by informing her about the hospital’s capabilities to handle such situations. The neonatal unit in the hospital is equipped to handle emergencies and care for preterm babies. This response is factual and directly addresses the patient’s concern about the baby’s well-being.
Choice B rationale
While it’s true that everyone worries about their baby when they’re in labor, this response doesn’t directly address the patient’s concern about the baby’s health and well-being. It’s more of a general statement and doesn’t provide the reassurance the patient is seeking.
Choice C rationale
This response acknowledges the patient’s feelings, which is an important aspect of patient care. However, it doesn’t provide any information or reassurance about the baby’s health. The patient is specifically asking about the baby’s well-being, so the response should focus on that.
Choice D rationale
This response could be misleading. While it’s true that the chances of survival for preterm babies improve with each passing week, it’s not guaranteed that a baby born at 32 weeks will be fine. It’s important to provide accurate information and not give false reassurances.
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale
The G in GTPAL stands for gravida, which is the number of times an individual has conceived, including any current pregnancy. In this case, G3 means the client has had three pregnancies, which includes two prior pregnancies and the current one.
Choice B rationale
The client’s record does not indicate that she is currently pregnant with twins, making this choice incorrect.
Choice C rationale
The A in GTPAL stands for the number of abortions, which refers to all times the individual has lost a pregnancy before 20 weeks. In this case, A1 means the client has had one abortion, indicating a risk for miscarriage.
Choice D rationale
The T in GTPAL stands for term births, which refers to the number of times an individual has carried a pregnancy to at least 37 weeks of gestation and delivered. In this case, T1 means the client has had one full-term birth.
Choice E rationale
The L in GTPAL stands for living children. In this case, L1 means the client has one living child.
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