Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a child who has Kawasaki disease. Which of the following systems should the nurse monitor in response to this diagnosis?
A. Gastrointestinal
Gastrointestinal:Kawasaki disease primarily affects blood vessels, and the gastrointestinal system is not the main target of this condition. While gastrointestinal symptoms can occur as part of the overall inflammatory response, such as abdominal pain, vomiting, or diarrhea, they are not the primary focus of concern in Kawasaki disease. The most critical system to monitor Kawasaki disease is the cardiovascular system, specifically the coronary arteries.
B. Respiratory
Respiratory:The respiratory system is not the primary system affected by Kawasaki disease. While respiratory symptoms can occur as part of the overall inflammatory response and fever associated with the disease, such as coughing or runny nose, they are not the main concern in Kawasaki disease. The primary system to monitor in this condition is the cardiovascular system, especially the coronary arteries.
C. Cardiovascular
Cardiovascular: This is the correct answer. Kawasaki disease is primarily a vasculitis (inflammation of blood vessels) that affects various blood vessels, including the coronary arteries. The inflammation of the coronary arteries can lead to coronary artery aneurysms and other cardiac complications. Monitoring the cardiovascular system is essential to detect any signs of coronary artery involvement and ensure timely intervention to prevent potential long-term cardiac problems.
D. Integumentary
Integumentary:The integumentary system (skin) is not the primary focus of Kawasaki disease. While some skin changes can occur during the acute phase of the disease, such as a rash or peeling skin on the hands and feet, these are not the primary concerns. Monitoring the cardiovascular system is critical in Kawasaki disease due to the risk of coronary artery inflammation and potential complications.
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Full Explanation
A. Gastrointestinal:
Kawasaki disease primarily affects blood vessels, and the gastrointestinal system is not the main target of this condition. While gastrointestinal symptoms can occur as part of the overall inflammatory response, such as abdominal pain, vomiting, or diarrhea, they are not the primary focus of concern in Kawasaki disease. The most critical system to monitor in Kawasaki disease is the cardiovascular system, specifically the coronary arteries.
B. Respiratory:
The respiratory system is not the primary system affected by Kawasaki disease. While respiratory symptoms can occur as part of the overall inflammatory response and fever associated with the disease, such as coughing or runny nose, they are not the main concern in Kawasaki disease. The primary system to monitor in this condition is the cardiovascular system, especially the coronary arteries.
C. Cardiovascular:
This is the correct answer. Kawasaki disease is primarily a vasculitis (inflammation of blood vessels) that affects various blood vessels, including the coronary arteries. The inflammation of the coronary arteries can lead to coronary artery aneurysms and other cardiac complications. Monitoring the cardiovascular system is essential to detect any signs of coronary artery involvement and ensure timely intervention to prevent potential long-term cardiac problems.
D. Integumentary:
The integumentary system (skin) is not the primary focus of Kawasaki disease. While some skin changes can occur during the acute phase of the disease, such as a rash or peeling skin on the hands and feet, these are not the primary concerns. Monitoring the cardiovascular system is critical in Kawasaki disease due to the risk of coronary artery inflammation and potential complications.
Similar Questions
A nurse is obtaining vital signs from a 2-month-old infant. The infant's heart rate is 190/min and his temperature is 40° C (104° F). The father asks the nurse why the infant's heart is beating so fast. Which of the following responses by the nurse is appropriate?
A. "This is within the expected range for your baby."
"This is within the expected range for your baby." - A heart rate of 190/min is above the normal expected range for a 2-month-old infant, which is typically between 120 to 160 beats per minute. This response would not address the elevated heart rate and fever.
B. "The fever is causing an increase in your baby's heart rate."
In this scenario, the infant has a heart rate of 190/min and a fever of 40°C (104°F). Fever in infants can cause an increase in heart rate, which is a normal physiological response to elevated body temperature. Fever is the body's way of responding to an infection or illness, and it triggers various physiological changes, including an increase in heart rate. This helps the body to circulate blood and deliver immune cells to fight off the infection.
C. "As your baby begins to fall asleep. his heart rate will decrease."
"As your baby begins to fall asleep, his heart rate will decrease." - While heart rate may decrease during sleep, it does not explain the elevated heart rate and fever observed in this situation.
D. "Your baby's heart is beating fast in an attempt to cool down his body."
"Your baby's heart is beating fast in an attempt to cool down his body." - While tachycardia (fast heart rate) can be associated with increased metabolic demands during fever, the main reason for the increased heart rate in this case is the fever itself, not the body's attempt to cool down. Fever is a response to infection or illness and can cause an increase in heart rate as part of the body's normal immune response.
Full Explanation
In this scenario, the infant has a heart rate of 190/min and a fever of 40°C (104°F). Fever in infants can cause an increase in heart rate, which is a normal physiological response to elevated body temperature. Fever is the body's way of responding to an infection or illness, and it triggers various physiological changes, including an increase in heart rate. This helps the body to circulate blood and deliver immune cells to fight off the infection.
The other options are not accurate or relevant to the infant's current condition:
A. "This is within the expected range for your baby." - A heart rate of 190/min is above the normal expected range for a 2-month-old infant, which is typically between 120 to 160 beats per minute. This response would not address the elevated heart rate and fever.
C. "As your baby begins to fall asleep, his heart rate will decrease." - While heart rate may decrease during sleep, it does not explain the elevated heart rate and fever observed in this situation.
D. "Your baby's heart is beating fast in an attempt to cool down his body." - While tachycardia (fast heart rate) can be associated with increased metabolic demands during fever, the main reason for the increased heart rate in this case is the fever itself, not the body's attempt to cool down. Fever is a response to infection or illness and can cause an increase in heart rate as part of the body's normal immune response.
A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?
A. "I will keep my baby in an upright position after feedings
"I will keep my baby in an upright position after feedings."Gastroesophageal reflux (GER) is a condition where the stomach contents flow back into the esophagus, which can cause spitting up or regurgitation in infants. Keeping the baby in an upright position after feedings can help reduce the likelihood of reflux episodes. By holding the baby in an upright position for about 30 minutes after feeding, gravity can aid in keeping the stomach contents from flowing back into the esophagus. The other statements are incorrect or do not address the management of gastroesophageal reflux:
B. "My baby's formula can be thickened with oatmeal.
"My baby's formula can be thickened with oatmeal." - Thickening formula with oatmeal is not a standard recommendation for managing GER in infants. In some cases, thickening formulas may be recommended, but it should be done under the guidance of a healthcare provider.
C. "I should position my baby side-lying during sleep.
"I should position my baby side-lying during sleep." A side-lying position is not recommended for sleep in infants, as it increases the risk of sudden infant death syndrome (SIDS). The safe sleep position for infants is on their back.
D. "I will have to feed my baby formula rather than breast milk."
"I will have to feed my baby formula rather than breast milk." - The type of feeding (formula or breast milk) does not directly impact the occurrence of gastroesophageal reflux. Both breast milk and formula can cause reflux in some infants. It is essential to discuss feeding options with a healthcare provider to determine the best approach for the individual infant's needs.
Full Explanation
A. "I will keep my baby in an upright position after feedings."
Gastroesophageal reflux (GER) is a condition where the stomach contents flow back into the esophagus, which can cause spitting up or regurgitation in infants. Keeping the baby in an upright position after feedings can help reduce the likelihood of reflux episodes. By holding the baby in an upright position for about 30 minutes after feeding, gravity can aid in keeping the stomach contents from flowing back into the esophagus.
The other statements are incorrect or do not address the management of gastroesophageal reflux:
B. "My baby's formula can be thickened with oatmeal." - Thickening formula with oatmeal is not a standard recommendation for managing GER in infants. In some cases, thickening formulas may be recommended, but it should be done under the guidance of a healthcare provider.
C. "I should position my baby side-lying during sleep." A side-lying position is not recommended for sleep in infants, as it increases the risk of sudden infant death syndrome (SIDS). The safe sleep position for infants is on their back.
D. "I will have to feed my baby formula rather than breast milk." - The type of feeding (formula or breast milk) does not directly impact the occurrence of gastroesophageal reflux. Both breast milk and formula can cause reflux in some infants. It is essential to discuss feeding options with a healthcare provider to determine the best approach for the individual infant's needs.
A nurse is caring for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?
A. Encourage the parents to rock the infant.
A. Encourage the parents to rock the infant:Rocking provides comfort and soothing for the infant. It helps reduce anxiety and promotes relaxation during the immediate postoperative period
B. Administer ibuprofen as needed for pain.
Administer ibuprofen as needed for pain:Administering ibuprofen as needed for pain is not typically recommended for infants under 6 months of age without specific instructions from the healthcare provider. Ibuprofen is generally avoided in young infants due to potential risks of adverse effects, especially in the immediate postoperative period.
C. Position the infant on her abdomen.
Position the infant on her abdomen: After cleft lip repair surgery, it is generally recommended to position the infant on her back to prevent any pressure on the surgical site and to minimize the risk of infection. Placing the infant on her abdomen may interfere with the healing process and increase the risk of complications.
D. Offer the infant a pacifier
Avoid the use of oral suction or placing objects in the mouth such as a tongue depressor, thermometer, straws, spoons, forks, or pacifiers.
Full Explanation
Correct answer: A
A. Encourage the parents to rock the infant: Rocking provides comfort and soothing for the infant. It helps reduce anxiety and promotes relaxation during the immediate postoperative period
B. Administer ibuprofen as needed for pain: Administering ibuprofen as needed for pain is not typically recommended for infants under 6 months of age without specific instructions from the healthcare provider. Ibuprofen is generally avoided in young infants due to potential risks of adverse effects, especially in the immediate postoperative period
C. Position the infant on her abdomen: After cleft lip repair surgery, it is generally recommended to position the infant on her back to prevent any pressure on the surgical site and to minimize the risk of infection. Placing the infant on her abdomen may interfere with the healing process and increase the risk of complications.
D. Offer the infant a pacifier.
Avoid the use of oral suction or placing objects in the mouth such as a tongue depressor, thermometer, straws, spoons, forks, or pacifiers.