When caring for the child with Kawasaki disease, the nurse should understand what principle of care?
The child's fever is usually responsive to antibiotics within 48 hours.
Aspirin is contraindicated.
Therapeutic management includes administration of gamma globulin and aspirin.
The principal area of involvement is the joints.
The Correct Answer is C
The correct answer is choice C. Therapeutic management includes administration of gamma globulin and aspirin.
Choice A rationale:
The child's fever in Kawasaki disease is not usually responsive to antibiotics within 48 hours. Kawasaki disease is an inflammatory condition of blood vessels, and it doesn't typically respond to antibiotics. The fever associated with Kawasaki disease often persists even with appropriate treatment, and the management focuses on reducing inflammation and preventing complications.
Choice B rationale:
Aspirin is not contraindicated in Kawasaki disease. In fact, aspirin is a key component of the therapeutic management of Kawasaki disease. It is used to reduce inflammation and prevent the development of coronary artery aneurysms, a severe complication of the disease. However, the dosing of aspirin in Kawasaki disease is different from its use for pain relief, and it should be administered under medical supervision.
Choice C rationale:
Therapeutic management of Kawasaki disease does include administration of gamma globulin and aspirin. Gamma globulin is given to reduce the risk of coronary artery involvement and aneurysm formation. Aspirin, at a specific dose regimen, is used to decrease inflammation and platelet aggregation, thus preventing clot formation in the coronary arteries.
Choice D rationale:
The principal area of involvement in Kawasaki disease is not the joints. Kawasaki disease primarily affects the blood vessels, particularly the coronary arteries. The inflammation of these arteries can lead to the development of coronary artery aneurysms, which is a critical concern in Kawasaki disease. Joint involvement is not a prominent feature of this condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Activity intolerance related to generalized weakness.
Choice A rationale:
Risk for injury related to depressed sensorium. This choice is not the most appropriate nursing diagnosis for a child with moderate anemia. While anemia can lead to fatigue and weakness, the main concern is the child's ability to tolerate physical activities, not the risk of injury due to a depressed sensorium.
Choice B rationale:
Decreased cardiac output related to abnormal hemoglobin. This choice is not the most suitable nursing diagnosis for a child with moderate anemia. While abnormal hemoglobin levels can affect cardiac output, moderate anemia typically doesn't lead to such a significant decrease in cardiac output that it becomes the primary nursing diagnosis. Activity intolerance is a more relevant concern.
Choice C rationale:
Activity intolerance related to generalized weakness. This is the most appropriate nursing diagnosis for a child diagnosed with moderate anemia. Moderate anemia results in a decrease in oxygen-carrying capacity, leading to generalized weakness and reduced ability to perform physical activities without becoming fatigued. The child's hemoglobin levels are likely low enough to cause noticeable activity intolerance.
Choice D rationale:
Risk for Injury related to dehydration and abnormal hemoglobin. This choice is not the best nursing diagnosis for a child with moderate anemia. Dehydration may exacerbate the effects of anemia, but the primary issue here is the anemia itself causing weakness and activity intolerance, which are better addressed with the choice C diagnosis.
Correct Answer is C
Explanation
The correct answer is choice C. Decreased oxygen-carrying capacity of blood.
Choice A rationale:
Anemia does not primarily result in a depressed hematopoietic system. In fact, anemia often occurs due to various factors that affect red blood cell production or lifespan. The hematopoietic system can be overactive in response to anemia, attempting to compensate for the reduced oxygen-carrying capacity of the blood.
Choice B rationale:
While some anemias may involve the presence of abnormal hemoglobin (e.g., sickle cell anemia), this is not the primary result of anemia. The primary consequence of anemia is a decreased ability of the blood to carry oxygen to the body's tissues.
Choice C rationale:
The correct choice. Anemia leads to a decreased oxygen-carrying capacity of the blood. Hemoglobin, the protein in red blood cells responsible for carrying oxygen, is reduced in quantity or function in various types of anemia. This results in inadequate oxygen delivery to tissues, potentially causing symptoms such as fatigue, weakness, pallor, and shortness of breath.
Choice D rationale:
Increased blood viscosity is not a primary result of anemia. Anemia tends to reduce blood viscosity because there are fewer red blood cells and less hemoglobin present, which makes the blood more fluid and less viscous. Increased blood viscosity is more commonly associated with conditions like polycythemia, where there is an excess of red blood cells.
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