Home » NCLEX » NCLEX-PN » Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?
A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?
A. administering immune globulin intravenously
B. assessing the extremities for edema, redness and desquamation every 8 hours
C. explaining progression of the disease to the client and his or her family
D. assessing heart sounds and rhythm
Correct Answer: C
Explanation/Reference:
Explanation:
Teaching the client and family about progression of the disease includes explaining when symptoms can be expected to improve and resolve. Knowledge of the course of the disease can help them understand that no permanent disruption in physical appearance will occur that could negatively affect body image.
Clients with Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary artery lesions and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to body image. The nurse assesses symptoms to assist in evaluation of treatment and progression of the disease.Health Promotion and Maintenance
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