A child has been admitted with Kawasaki disease and is started on ...

[crazycityslicker]

A child has been admitted with Kawasaki disease and is started on aspirin and warfarin (Coumadin). For which nursing diagnosis does the nurse plan interventions as the priority?
 
  A.
  Acute pain related to mouth redness and cracked lips
  B.
  Altered body image related to peeling skin rash
  C.
  Altered nutrition: less than body requirements
  D.
  Risk for bleeding related to medication effects

Question 2

The nurse is assigned to four patients on the pediatric progressive care unit. After receiving shift report, which patient should the nurse see first?
 
  A.
  Blood pressure of 88/56 mm Hg in 4-year-old child with heart failure
  B.
  Child crying inconsolably after his parents went home
  C.
  Pain 5/10 in a child 2 days after cardiac surgery
  D.
  Temperature 104.6 F (40.3 C) 3 days after dental visit

[ynlevi]

Answer to Question 1

ANS: D
Actual nursing diagnoses take priority over risk for diagnoses when the actual diagnoses exist. There is no information in the stem to show that the child has impaired mucous membranes leading to pain, an altered body image related to rash, or altered nutrition, although all of these are possible for this child. Risk for injury is the priority because the child is taking two medications that alter coagulation, and for patient safety, this is a critical diagnosis.

Answer to Question 2

ANS: D
This child likely has infective endocarditis or bacterial endocarditis. Any high fever after an invasive procedure or dental cleaning needs to be investigated for this possibility. The blood pressure of 88/56 mm Hg is at about the 50 percentile for a 4-year-old and would be considered adequate. Pain is an expected finding after surgery and needs to be treated, but not as the priority. The crying child could be comforted by a nursing assistant, child-life specialist, social worker, or even a volunteer until the nurse can see the child.

[crazycityslicker]

Gracias!

[Alyson.hiatt@yahoo.com]

Excellent