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?
Decreased Heart Rate
Peeling of the soles of the feet
Pain in weight-bearing joints
Fever unresponsive to antipyretics
Determine whether the fundus is midline.
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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Correct Answer is B
Explanation
Rationale:
A. Triglycerides within the normal range do not indicate a need for additional nutrients.
B. A low albumin level of 2.8 g/dL indicates poor protein status and may suggest that the client requires additional protein in their enteral feeding to help with healing and overall nutrition.
C. A creatinine level of 1.1 mg/dL is within normal limits and does not indicate a need for additional nutrients.
D. Alkaline phosphatase at 118 units/L is within the normal range and does not suggest a deficiency requiring additional nutrients.
Correct Answer is A
Explanation
Rationale:
A. Elevating the affected leg is an important intervention for reducing swelling and promoting venous return, which can help alleviate discomfort and prevent further complications.
B. Placing cold compresses on the edematous area may provide temporary relief but is not a standard intervention for deep-vein thrombosis and could potentially harm tissue if applied for too long.
C. Restricting the client to 1 L of fluid per day is inappropriate, as adequate hydration is essential for maintaining good venous health and preventing further complications.
D. Maintaining the client on bed rest is not necessary; while rest is important, early ambulation is encouraged to promote circulation and prevent further clot formation unless contraindicated.