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 ["C","D"]
Explanation
A. Object permanence is a cognitive ability typically developed during the sensorimotor stage (0-2 years), not during the concrete operational stage (7-11 years).
B. Egocentric thinking is characteristic of the preoperational stage (2-7 years) and decreases as children enter the concrete operational stage.
C. The ability to perform logical operations on concrete objects is a hallmark of the concrete operational stage, where children can think logically about physical objects and events.
D. Understanding the concept of conservation, which refers to recognizing that quantity does not change despite changes in shape or arrangement, is a key characteristic of the concrete operational stage.
E. Use of symbolic play is more characteristic of the preoperational stage, where children engage in imaginative play rather than concrete operations.
Correct Answer is A
Explanation
A. Holding breath for 10 seconds after inhaling the medication allows for better absorption of the medication in the lungs, indicating understanding of proper inhaler technique.
B. Taking a quick inhalation is incorrect; the client should take a slow, deep breath to ensure the medication reaches the lungs effectively.
C. Waiting 10 minutes between inhalations is not necessary unless specifically instructed; usually, a second puff can be taken after 1-2 minutes if needed.
D. The client should exhale before inhaling the medication, not while it is being released; exhaling first clears the lungs for a more effective inhalation.