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 A
Explanation
A. A child whose parents consistently answer questions on their behalf may indicate a lack of autonomy and could be a sign of potential abuse or neglect, as it may suggest the parents are controlling or overly involved.
B. A child who has frequent visitors does not inherently suggest abuse; in fact, it could indicate support and care from family or friends.
C. Frequent use of the call light could indicate a child's need for assistance or comfort but does not directly correlate with abuse.
D. A child with a BMI indicating obesity is not a definitive indicator of abuse; it may relate to dietary habits or lifestyle factors rather than abuse.
Correct Answer is B
Explanation
A. Doubling the dose if a dose is missed can increase the risk of bleeding and is not recommended for warfarin. Instead, the client should take the missed dose as soon as remembered unless it's almost time for the next dose.
B. Using an electric razor is recommended to minimize the risk of cuts and bleeding, which is particularly important for clients on anticoagulants like warfarin.
C. While increasing fiber intake can be beneficial for overall health, it is not specifically necessary for addressing constipation related to warfarin therapy.
D. While mild nosebleeds may occur, they are not typically common during initial treatment. Clients should be informed to report any unusual or severe bleeding.