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. A stool fat content analysis can suggest malabsorption issues but does not specifically confirm cystic fibrosis.
B. The sweat chloride test measures the amount of chloride in the sweat, with elevated levels confirming a diagnosis of cystic fibrosis.
C. Pulmonary function tests assess lung function but are not definitive for diagnosing cystic fibrosis.
D. A sputum culture can identify respiratory infections but is not specific for cystic fibrosis diagnosis.
Correct Answer is A
Explanation
A. It is recommended to replace the child's toothbrush after 24 hours of starting antibiotics to prevent reinfection or spreading the bacteria.
B. A child with acute group A B-hemolytic streptococci should remain home from school until they have been on antibiotics for at least 24 hours, not for a full week, to reduce the risk of spreading the infection.
C. Warm compresses may be used to alleviate discomfort associated with sore throats or swollen glands; there is no contraindication to their use in this context.
D. Intramuscular injections are not a standard treatment for this condition; antibiotics are typically administered orally unless there are complications requiring different management.