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A nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. Which of the following findings should the nurse expect?

A.

Decreased Heart Rate

B.

Peeling of the soles of the feet

C.

Pain in weight-bearing joints

D.

Fever unresponsive to antipyretics

E.

Determine whether the fundus is midline.

Answer and Explanation

The Correct Answer is D

Rationale:

 

A. Decreased heart rate is not typical; children with Kawasaki disease often experience tachycardia. 

 

B. Peeling of the soles of the feet is more commonly observed in the convalescent phase of Kawasaki disease rather than the acute phase. 

 

C. Pain in weight-bearing joints can occur in Kawasaki disease but is not the hallmark symptom during the acute phase. 

 

D. Fever unresponsive to antipyretics is a classic finding in the acute phase of Kawasaki disease, indicating ongoing inflammation and a need for further intervention.


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View Related questions

Correct Answer is C

Explanation

Rationale:

A. Applying a cold compress is not recommended for DVT; instead, heat may be more appropriate to alleviate discomfort and improve circulation.

B. Massaging the affected extremity is contraindicated as it can dislodge the clot and lead to complications such as pulmonary embolism.

C. Instructing the client to elevate the affected extremity helps reduce swelling and promote venous return, making it the best action.

D. Assessing pulses proximal to the affected area is important for monitoring circulation, but it is not the primary intervention for managing DVT.

Correct Answer is B

Explanation

Rationale:

A. Surgical asepsis (sterile technique) should be used for suctioning to prevent infection, not medical asepsis.

B. Applying suction for no longer than 10 seconds is appropriate to prevent hypoxia and trauma to the airway.

C. Advancing the catheter 2 cm after resistance is met is not advised; the catheter should not be forced beyond resistance to avoid injury.

D. The catheter should not be withdrawn if the client begins coughing; instead, it indicates the need for suctioning. If coughing occurs, the nurse should ensure the patient can breathe and may need to suction carefully.

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