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 B
Explanation
A. Use a padded tongue blade:
Incorrect: Inserting anything into the child's mouth, including a padded tongue blade, is not recommended during a seizure. It can lead to oral and airway injuries. It's important to keep the airway clear, but this is achieved by positioning the child laterally.
B. Position the child laterally.
Correct Answer: This is the correct action. Placing the child on their side helps prevent aspiration of fluids and promotes a clear airway during the seizure. It also reduces the risk of injury.
C. Restrain the child's arms:
Incorrect: Restraining the child's arms can increase the risk of injury and is not recommended during a seizure. It's crucial to ensure a safe environment and prevent injury, but physically restraining the child is not the appropriate approach.
D. Attempt to stop the seizure:
Incorrect: It is not within the nurse's capacity to immediately stop a seizure. Seizures are neurological events, and they need to run their course. The focus should be on ensuring the safety of the child during the seizure.
Correct Answer is ["B","C","E"]
Explanation
A. Symptoms are continuous throughout the day:
Incorrect: Continuous symptoms throughout the day are more indicative of moderate or severe persistent asthma, not mild persistent asthma.
B. Daytime symptoms occur more than twice a week:
Correct Answer: Children with mild persistent asthma may experience symptoms more than twice a week, but less than once a day.
C. Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value:In mild persistent asthma, pulmonary function tests (e.g., PEF or FEV1) remain normal or close to normal, with values typically ≥80% of the predicted value, reflecting good lung function between episodes.
D. Nighttime symptoms occur approximately twice a month:
Mild persistent asthma often involves nighttime symptoms or awakenings occurring 3–4 times per month. If nighttime symptoms occur more frequently (e.g., once weekly), it suggests moderate persistent asthma.
E. Minor limitations occur with normal activity:Children with mild persistent asthma may experience minor limitations in their normal activities. These limitations are not severe and do not significantly impact daily life.
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