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. Similar to the previous question, a quick inhalation is not recommended; the child should take a slow, deep breath for effective medication delivery.
B. Taking the medication 5 minutes before playing sports is ideal as it allows the medication to work quickly, ensuring better performance and control of asthma symptoms during activity.
C. Cleaning the mouthpiece with warm water every 2 weeks is insufficient; it should be cleaned more frequently, typically after each use, to maintain hygiene.
D. Waiting 10 seconds between inhalations is appropriate, but the focus on the timing before sports is critical for proper management of asthma symptoms.
Correct Answer is A
Explanation
Rationale:
A. A report of chest pain is an adverse effect of epinephrine, which can increase myocardial oxygen demand and cause angina or myocardial ischemia.
B. Hypotension is not a common effect after administering epinephrine; it typically causes hypertension due to vasoconstriction.
C. Ecchymosis is not a known adverse effect of epinephrine and may be related to other factors.
D. Tinnitus is not a recognized adverse effect of epinephrine and does not commonly occur after administration.