A child is admitted to the pediatric unit with a diagnosis of Kawasaki disease. Which nursing intervention is most appropriate during this initial phase?
Administering antibiotics
Monitoring for signs of coronary artery aneurysms
Providing comfort measures for peeling skin on the hand
Administering intravenous immunoglobulin (IVIG)
The Correct Answer is D
A. Administering antibiotics is not appropriate as Kawasaki disease is not caused by a bacterial infection; it is an inflammatory condition.
B. While monitoring for signs of coronary artery aneurysms is essential, the immediate intervention needed in the initial phase is to administer IVIG to mitigate inflammation and prevent complications.
C. Providing comfort measures for peeling skin is supportive but does not address the critical treatment needs in Kawasaki disease.
D. Administering intravenous immunoglobulin (IVIG) is the priority nursing intervention as it helps reduce inflammation and the risk of developing cardiovascular complications associated with Kawasaki disease.
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Correct Answer is B
Explanation
A. Using a booster seat until the child reaches the appropriate height for a seatbelt is correct and aligns with safety guidelines for child passengers.
B. Allowing a child to ride in the front seat while still using a booster seat is unsafe; children should remain in the back seat until they are at least 13 years old.
C. Ensuring that the child wears a helmet while riding a bicycle is an important safety measure and demonstrates understanding of injury prevention.
D. Teaching the child to avoid running into the street without looking shows awareness of pedestrian safety and the need for supervision and education about traffic safety.
Correct Answer is D
Explanation
A. While anxiety and withdrawal are concerning, they may not require immediate intervention compared to behaviors that pose risks to the child or others.
B. A stable child with a concerned parent may benefit from reassurance and support, but they do not require urgent intervention.
C. Stomach pain without an apparent cause should be assessed, but it may not be as urgent as aggressive behavior that can harm others.
D. A child exhibiting aggressive behavior poses a risk to themselves and others, necessitating immediate assessment and intervention to ensure safety and manage the behavior effectively.