The nurse is caring for a school-age child with Kawasaki disease who has experienced a history of a fever for 6 days. Which intervention should the nurse prioritize during the initial treatment phase of the illness?
Obtain temperature assessment prior to aspirin administration.
Maintain meticulous oral hygiene and lubrication of lips.
Provide passive range of motion exercises.
Monitor fluid intake and output and daily weight.
The Correct Answer is D
Rationale:
A. Obtain temperature assessment prior to aspirin administration: Monitoring temperature is important to evaluate the effectiveness of antipyretics. However, it does not address the risk of fluid imbalance or cardiovascular complications, which are more urgent in Kawasaki disease.
B. Maintain meticulous oral hygiene and lubrication of lips: Oral care helps prevent discomfort from mucous membrane changes such as cracked lips and strawberry tongue. Although important for comfort, it is not the priority during the acute inflammatory phase.
C. Provide passive range of motion exercises: Passive range of motion can prevent joint stiffness due to inflammation. While beneficial, musculoskeletal interventions are secondary to monitoring for complications related to cardiovascular status and hydration.
D. Monitor fluid intake and output and daily weight: Monitoring intake, output, and weight is crucial because Kawasaki disease can cause systemic inflammation, edema, and potential cardiac complications like myocarditis or heart failure. Accurate fluid balance assessment helps prevent worsening cardiac function and guides clinical management in the acute phase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E","F"]
Explanation
Rationale:
A. Slowly increase caloric content using enteral nutritional formula powder: Gradually increasing caloric density helps meet the infant’s energy requirements without overloading the gastrointestinal system, which is crucial for infants with heart failure and fatigue during feeds.
B. Feed the infant on demand: These infants are at high risk for fatigue, and feeding requires a significant amount of energy. This can lead to decreased intake and further weight loss. A structured feeding schedule is more appropriate to ensure adequate caloric intake.
C. Make sure the infant is well rested before feeds: Ensuring the infant is rested prior to feeding reduces fatigue, improves endurance, and increases the likelihood of adequate intake.
D. Wake the infant up to eat: Infants with heart failure and failure to thrive may not wake spontaneously for feeds; waking them ensures they receive adequate nutrition for growth and energy.
E. Stroke the cheek to encourage sucking: Tactile stimulation can promote sucking reflexes and help the infant feed more effectively, which is particularly important in fatigued infants.
F. Initiate a three-hour feeding schedule: Infants with heart failure fatigue easily. A structured feeding schedule, such as every 3 hours, is critical to ensure the infant receives consistent nutrition and hydration. This approach prevents the infant from becoming too hungry and ensures that feeding sessions are spaced out enough for the infant to rest and recover.
G. Feed for one-hour duration: Prolonged feeding times are not recommended for infants with fatigue; feeds should be effective but brief to prevent exhaustion.
H. Give gavage feedings via percutaneous endoscopic gastrostomy (PEG) tube: PEG tube feedings are not indicated at this time since the infant is able to feed orally with support and stimulation.
Correct Answer is A
Explanation
Rationale:
A. Wear a supportive bra at all times: Wearing a well-fitting, supportive bra helps relieve pressure on engorged breasts and provides comfort while maintaining proper breast support. It can reduce swelling, prevent tissue damage, and make breastfeeding or pumping more manageable during periods of overfull breasts.
B. Take two acetaminophen to relieve the discomfort: Acetaminophen may help reduce pain, but it does not address the underlying cause of engorgement or prevent worsening discomfort. Medication alone is not sufficient as a primary strategy for managing engorged breasts.
C. Use breast cream to help prevent discomfort: Breast creams are designed to prevent nipple soreness or cracking but do not alleviate discomfort from breast engorgement. This intervention would not directly reduce swelling or pressure in overfull breasts.
D. Put a heating pad on the breasts while they are engorged: Applying heat to engorged breasts can worsen swelling by increasing blood flow and may intensify discomfort. Instead, cold compresses before feeding or gentle massage toward the nipple during feeding is more effective in relieving engorgement.
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