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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Placing a newborn in a forward-facing car seat is unsafe and not recommended due to the risk of injury in case of a crash.
B. Turning the baby's car seat around at 15 pounds is too early. Rear-facing car seats are recommended until the child reaches the weight or height limit set by the manufacturer.
C. Positioning the baby at a 45-degree angle in the car seat helps prevent airway obstruction and allows for proper breathing and spinal alignment.
D. Placing a baby in the front seat, even with the airbag turned off, is not recommended due to the risk of injury from airbag deployment.

A. BP 150/92 mm Hg B. Flushed face C. Pulse rate 100/min D. Negative clonus

Correct Answer is D

Explanation

A. A blood pressure reading of 150/92 mm Hg is indicative of hypertension, a symptom of preeclampsia, but it is not a therapeutic effect of magnesium sulfate.
B. A flushed face is not a therapeutic effect of magnesium sulfate and may indicate adverse effects such as magnesium toxicity.
C. A pulse rate of 100/min is within the normal range and is not a specific therapeutic effect of magnesium sulfate.
D. Negative clonus, assessed by dorsiflexing the client's foot and observing for absence of rhythmic oscillations or beats, indicates a therapeutic level of muscle relaxation provided by magnesium sulfate to prevent seizures in clients with preeclampsia

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching about car seat safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV Infusion. For which of the following therapeutic effects should the nurse monitor the client?

Correct Answer is D

Explanation

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