A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?
Monitor the child's cardiac status.
Give scheduled doses of acetaminophen every 6 hr.
Provide stimulation with children of the same age in the play room.
Administer antibiotics via intermittent IV bolus for 24 hr.
The Correct Answer is A
A. Kawasaki disease involves inflammation of the blood vessels and can lead to serious cardiac complications, including coronary artery aneurysms. Monitoring cardiac status is essential to detect and manage these risks.
B. While managing fever is a part of treating Kawasaki disease, acetaminophen is typically used as needed rather than on a strict schedule unless fever is persistent.
C. During the acute phase of Kawasaki disease, children often feel very irritable and unwell; large group activities may be overwhelming and inappropriate.
D. Kawasaki disease is not caused by a bacterial infection, and antibiotics are not part of the treatment. Instead, treatment usually involves high-dose aspirin and intravenous immunoglobulin.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While this may be a risk factor for some behaviors, it is not as strong a predictor of violence as a history of actual violent behavior.
B. Although statistics show higher rates of violence among males, it's not a specific predictor for individual behavior.
C. Previous violent behavior is the strongest predictor of future violence.
Understanding a client's history of violence is critical in assessing risk and planning interventions.
D. While certain types of delusions may increase risk, they are not as definitive in predicting violence as past violent behaviors.
Correct Answer is C
Explanation
A. Informing the client that the transfusion is mandatory disregards the client's autonomy and right to refuse treatment.
B. While documenting the client's refusal is important, notifying risk management about the refusal is not necessary unless there are specific facility policies or legal requirements.
C. Documenting the client's refusal in the medical record ensures that the refusal is properly recorded and communicated to the healthcare team, protecting both the client's autonomy and the healthcare provider.
D. While it's important to respect the client's autonomy, suggesting alternative therapies may not be appropriate in this context and could undermine the client's decision-making process.
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