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
Respiratory
Cardiovascular
Integumentary
The Correct Answer is C
A. Gastrointestinal:
Kawasaki disease primarily affects blood vessels, and the gastrointestinal system is not the main target of this condition. While gastrointestinal symptoms can occur as part of the overall inflammatory response, such as abdominal pain, vomiting, or diarrhea, they are not the primary focus of concern in Kawasaki disease. The most critical system to monitor in Kawasaki disease is the cardiovascular system, specifically the coronary arteries.
B. Respiratory:
The respiratory system is not the primary system affected by Kawasaki disease. While respiratory symptoms can occur as part of the overall inflammatory response and fever associated with the disease, such as coughing or runny nose, they are not the main concern in Kawasaki disease. The primary system to monitor in this condition is the cardiovascular system, especially the coronary arteries.
C. Cardiovascular:
This is the correct answer. Kawasaki disease is primarily a vasculitis (inflammation of blood vessels) that affects various blood vessels, including the coronary arteries. The inflammation of the coronary arteries can lead to coronary artery aneurysms and other cardiac complications. Monitoring the cardiovascular system is essential to detect any signs of coronary artery involvement and ensure timely intervention to prevent potential long-term cardiac problems.
D. Integumentary:
The integumentary system (skin) is not the primary focus of Kawasaki disease. While some skin changes can occur during the acute phase of the disease, such as a rash or peeling skin on the hands and feet, these are not the primary concerns. Monitoring the cardiovascular system is critical in Kawasaki disease due to the risk of coronary artery inflammation and potential complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should recommend bananas as a safe food choice for a 2-year-old child. Bananas are soft and easy to chew, making them safe for young children. They do not pose a choking hazard, unlike grapes, raw carrots, or celery.
Option B (Grapes) can be a choking hazard for young children, especially if they are not cut into small pieces or are given whole.
Option C (Raw carrots) and Option D (Celery) are hard and crunchy, and they require more chewing, which may not be safe for a 2-year-old child who is still developing their chewing and swallowing abilities.
As a general guideline, when selecting foods for young children, it is essential to choose soft, easily chewable, and non-choking hazard options to promote safe eating and reduce the risk of choking incidents.
Correct Answer is B
Explanation
The nurse should clarify the prescription to administer sodium biphosphate/sodium phosphate because it is a laxative and is contraindicated in a child with suspected appendicitis. The use of laxatives or enemas can potentially worsen the condition by increasing the risk of perforation or rupture of the inflamed appendix.
A. Monitoring oral temperature every 4 hours is important to assess for signs of infection or worsening condition.
C. Maintaining NPO status is essential to avoid stimulating the digestive system and to prepare for possible surgery.
D. Medicating the client for pain every 4 hours as needed is appropriate to manage pain and provide comfort while the child awaits further evaluation or treatment.
Remember, it's crucial to avoid the use of laxatives, enemas, or any other interventions that can potentially aggravate the inflamed appendix in a child with suspected appendicitis.
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