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","E"]
Explanation
A. Vocal changes are more pronounced in boys during puberty; girls typically do not experience significant vocal changes.
B. Height does not decrease; instead, girls experience a growth spurt during puberty before reaching their adult height.
C. Breast development is one of the first signs of puberty in girls, typically occurring between ages 8 and 13.
D. Menarche, the first menstrual period, usually occurs later in puberty and is an important milestone indicating the onset of reproductive capability.
E. Increased axillary hair growth is also a common change that occurs during puberty as hormone levels rise.
Correct Answer is A
Explanation
A. Crushed ice is appropriate after a tonsillectomy as it can help soothe the throat and is a clear liquid that is easy for the child to swallow.
B. Cranberry juice is acidic, which can irritate the throat and is generally not recommended immediately after tonsillectomy.
C. Orange juice is also acidic and could cause discomfort to the healing throat tissues, making it unsuitable for post-operative care.
D. A vanilla milkshake may be too thick for the child to swallow comfortably after surgery and can pose a risk of choking.