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. Whitish vesicles located across the chest:
Incorrect: This description does not match the characteristic appearance or location of Koplik's spots in measles.
B. Small blue-white spots with a red base found on the buccal mucosa:
Correct Answer: Koplik's spots are small, blue-white spots with a red base that typically appear on the buccal mucosa (inner lining of the cheeks). These spots are characteristic of measles and are considered a diagnostic feature.
C. Pinpoint petechiae noted on both legs:
Incorrect: Petechiae are small, reddish-purple spots that result from bleeding under the skin. They are not characteristic of Koplik's spots in measles.
D. Petechiae spots that are reddish and pinpoint on the soft palate:
Incorrect: While petechiae can occur in various conditions, they are not characteristic of Koplik's spots in measles. Koplik's spots specifically manifest as small blue-white spots on the buccal mucosa.
Correct Answer is B
Explanation
A. It is inconclusive
Explanation: A serum phenylalanine level within the normal range is considered conclusive in ruling out phenylketonuria. Inconclusive results typically occur when there are issues with the sample or testing process.
B. It is negative
Explanation:
A serum phenylalanine level of 1 mg/dL (60.5 mcmol/L) in a 2-week-old infant is within the normal range. In the context of phenylketonuria (PKU) screening, a "negative" result means that the phenylalanine levels are within the expected range, and there is no evidence of phenylketonuria.
C. It requires rescreening at age 6 weeks.
Explanation: If the initial screening result is within the normal range, rescreening at age 6 weeks may not be necessary for phenylketonuria. The timing and need for rescreening may vary based on local protocols and individual patient factors.
D. It is positive
Explanation: A positive result for phenylketonuria would indicate that the serum phenylalanine levels are elevated, suggesting a potential diagnosis of PKU. In this case, the result is negative, meaning there is no evidence of PKU.
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