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. 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.
Correct Answer is ["C","D","E"]
Explanation
A. Pertussis, or whooping cough, primarily affects the respiratory tract, particularly the trachea and bronchi, not just the nostrils.
B. Pertussis is caused by the bacterium Bordetella pertussis, making this statement incorrect as the infection is bacterial, not viral.
C. The toxins released by Bordetella pertussis damage the cilia of epithelial cells in the respiratory tract, leading to difficulty in clearing secretions.
D. The inflammation of the lungs and airways is a characteristic response to the infection, contributing to the symptoms of coughing and difficulty breathing.
E. The production of thick, mucus secretions is a hallmark of pertussis, which makes it challenging for the child to expel them, leading to severe coughing fits.