A nurse is preparing for the admission of a child with a diagnosis of acute-stage Kawasaki disease. On assessment of the child, the nurse expects to note which clinical manifestation of the acute stage of the disease?
a) cracked lips
b) a normal appearance
c) conjunctival hyperemia
d) desquamation of the skin
Ans: c) conjunctival hyperemia
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A nurse has delegated the task of ambulating a patient to two nursing assistants. Despite the patient's appearance, assistance of two people is needed for safe ambulation. The nurse discovers the patient being ambulated by only one aide
What should be the nurse's first action? 1. Demand to know why a second aide is not assisting with this patient. 2. Assist the aide in completion of the ambulation. 3. Scold the second aide for not carrying through with the delegated task. 4. Immediately initiate disciplinary actions against both aides for not following directions.
A client diagnosed with chronic alcohol use disorder is being discharged from an inpatient treatment facility after detoxification
Which client outcome related to Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with the client during discharge teaching? A. After discharge, the client will immediately attend 90 AA meetings in 90 days. B. After discharge, the client will rely on an AA sponsor to help control alcohol cravings. C. After discharge, the client will incorporate family in AA attendance. D. After discharge, the client will seek appropriate deterrent medications through AA.
Which of these blood pressure measurements indicates hypertension?
a. 120/70 and 140/90 mm Hg b. 138/90 and 120/80 mm Hg c. 150/100 and 110/60 mm Hg d. 148/90 and 160/100 mm Hg
Ten minutes after the transfusion of a unit of packed red blood cells was initiated, the client complains of a headache. The nurse assesses that the client has slight shortness of breath and feels warm to the touch. What action by the nurse is priority?
1. Notify the client's physician. 2. Discontinue the transfusion. 3. Slow the rate of the transfusion. 4. Prepare to resuscitate the client.