On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease?
Cracked lips
Desquamation of the skin
Normal appearance
Conjunctival hyperemia
The Correct Answer is D
A. Cracked lips:
Incorrect: While red, cracked lips are part of the mucous membrane changes seen in Kawasaki disease, they are not specific to the acute stage. Mucous membrane changes can occur in both the acute and subacute stages.
B. Desquamation of the skin:
Incorrect: Desquamation, or peeling of the skin, is more characteristic of the subacute or convalescent stages of Kawasaki disease, particularly on the fingers and toes.
C. Normal appearance:
Incorrect: In the acute stage, the child with Kawasaki disease typically exhibits signs of illness, including fever and other clinical manifestations. A "normal appearance" would not be expected in the acute stage.
D. Conjunctival hyperemia.
Explanation: Conjunctival hyperemia, or redness of the eyes, is a common clinical manifestation of the acute stage of Kawasaki disease. Other typical signs and symptoms during this stage include fever, mucous membrane changes (such as red, cracked lips), changes in the extremities, rash, and cervical lymphadenopathy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Carry a water bottle with me because I drink a lot of water."
Explanation: Staying hydrated is crucial, especially for individuals with paralysis who may be prone to urinary issues. Carrying a water bottle is a good practice to maintain adequate hydration.
B. "Use a suppository every night to have a bowel movement."
Explanation: Using a suppository for regular bowel movements is a positive self-care behavior. It helps manage bowel care, which is important for individuals with paralysis.
C. "I do wheelchair exercises while watching TV."
Explanation: Engaging in wheelchair exercises to maintain mobility is a positive self-care behavior. It helps prevent complications related to being sedentary, such as muscle atrophy.
D. "I only need to catheterize myself twice every day."
Explanation: This statement may indicate a need for further teaching. Individuals with paralysis, especially due to conditions like spina bifida, often have neurogenic bladder dysfunction. They typically require more frequent catheterization, potentially every 4-6 hours, to ensure adequate bladder emptying and reduce the risk of complications like urinary tract infections (UTIs) or bladder infections.
Correct Answer is B
Explanation
A. Test the urine for protein.
Explanation: Testing urine for protein is not a priority nursing intervention in the preoperative period for an infant with hydrocephalus. The focus is on preventing complications related to immobility and positioning.
B. Reposition the infant frequently.
Explanation:
Repositioning the infant frequently is a crucial intervention to prevent complications such as pressure ulcers (bedsores). Infants with hydrocephalus may be at an increased risk of skin breakdown due to prolonged immobility and pressure on specific areas. Repositioning helps distribute pressure, improves circulation, and reduces the risk of skin breakdown.
C. Assess blood pressure every 15 minutes.
Explanation: While monitoring blood pressure is important in certain situations, it is not typically the priority for an infant with hydrocephalus in the preoperative period. The focus is on preventing skin breakdown through repositioning.
D. Provide a stimulating environment.
Explanation: While providing a stimulating environment can be beneficial for infant development, it is not the priority in the preoperative period for an infant with hydrocephalus. The primary concern is addressing potential complications related to immobility, such as skin breakdown.
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