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Which information should the nurse reinforce to the parents of a child recently diagnosed with Kawasaki disease?
- A. It is also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes.'
- B. In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain.'
- C. Kawasaki disease occurs most often in boys, children younger than age 5 and children of Asian descent.'
- D. Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks.'
Correct Answer: C
Rationale: Kawasaki disease occurs most often in boys, children younger than age 5 and children of Asian descent, particularly Japanese. Other findings in the initial phase are extremely red eyes (conjunctivitis), a rash on the main part of the body (trunk) and in the genital area, red, dry, cracked lips; a red, swollen tongue resembling a strawberry; swollen, red skin on the palms of the hands and the soles of the feet; swollen lymph nodes in the neck.
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The nurse is instructing the client who is to have surgery. According to Medicare's Surgical Care Improvement Project, what instruction is important for the client to receive prior to arrival at the hospital to prevent postoperative infection?
- A. Arrive in time to receive an antibiotic before surgery.
- B. Notify the nurse of any antibiotic and food allergies.
- C. Be sure to wash your hands before coming to the hospital.
- D. Do not shave hair from the surgical incision site.
Correct Answer: D
Rationale: D: Avoiding shaving prevents skin lacerations that increase infection risk. A, B: While important, they are managed in-hospital. C: Hand washing by the client is less critical.
The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the provider?
- A. nausea and vomiting
- B. fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
- C. diffuse macular rash
- D. muscle tenderness
Correct Answer: B
Rationale: fever of 103 degrees Fahrenheit (39.5 degrees Celsius). Persistent, prolonged fever may be an indication that the antibiotics are not effective and may need to be changed.
The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test?
- A. I can't lie in one position for more than thirty minutes.'
- B. I am allergic to shrimp.'
- C. I suffer from claustrophobia.'
- D. I developed a severe headache after a spinal tap.'
Correct Answer: B
Rationale: I am allergic to shrimp.' A client undergoing myelography should be questioned carefully about allergies to iodine and iodine-containing substances such as seafood. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergic reaction could even include seizures.
A client with pneumococcal pneumonia was started on antibiotics 16 hours ago. During the nurse's initial evening rounds the nurse notices a foul taste and smell to the client's sputum. Which one would alert the nurse to a complication?
- A. I have a sharp pain in my chest when I take a breath.'
- B. I have been coughing up foul-tasting, brown, thick sputum.'
- C. I have been sweating all day.'
- D. I feel hot off and on.'
Correct Answer: B
Rationale: Foul smelling and tasting sputum signals a risk of a lung abscess. This puts the client in grave danger since abscesses are often caused by anaerobic organisms. This client most likely would need a change of antibiotics. Sharp chest pain on inspiration called pleuritic pain is an expected finding with this type of pneumonia. The other options are expected in the initial 24 to 48 hours of therapy for infections.
The client who has airborne precautions asks the nurse not to shut his door. Which response by the nurse is most appropriate?
- A. "If I open the door you will need to always wear a mask."
- B. "The door must be kept closed, but I can open the curtains."
- C. "Don't worry; I can leave the door open if it's bothering you."
- D. "I'm sorry, but I can only leave the door partially open."
Correct Answer: B
Rationale: B: Keeping the door closed contains airborne pathogens; opening curtains reduces isolation feelings. A, C, D: Open or partially open doors risk pathogen spread.