# A 2-year-old toddler with Kawasaki disease is admitted to the pediatric unit. The child has been febrile for 6 days and exhibits bilateral conjunctival injection, strawberry tongue, and polymorphous rash. Which nursing action should be the highest priority?

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## 문제

A 2-year-old toddler with Kawasaki disease is admitted to the pediatric unit. The child has been febrile for 6 days and exhibits bilateral conjunctival injection, strawberry tongue, and polymorphous rash. Which nursing action should be the highest priority?

## 보기

1. Administer aspirin as prescribed to reduce fever and inflammation
2. Apply cool compresses to reduce skin irritation from the rash
3. Monitor for signs of cardiac complications and arrhythmias **✔ 정답**
4. Encourage increased fluid intake to prevent dehydration

**정답: 3**

## 해설

Monitoring for cardiac complications is the highest priority because Kawasaki disease can cause life-threatening cardiovascular issues like coronary artery aneurysms and arrhythmias.

## 심화 해설

Clinical Context and Priority Setting

This question presents a 2-year-old toddler in the acute phase of Kawasaki disease (KD), evidenced by prolonged fever, bilateral conjunctival injection, strawberry tongue, and polymorphous rash. While all listed nursing actions are relevant to the care of a child with KD, the NCLEX-RN requires you to prioritize based on the most significant risk to life and long-term health. The primary pathophysiological concern in KD is systemic vasculitis affecting medium-sized arteries, with a predilection for the coronary arteries. The development of coronary artery abnormalities (CAAs), including aneurysms, is the most serious complication, leading to myocardial ischemia, infarction, and sudden death. Therefore, vigilant monitoring for cardiac complications becomes the highest priority nursing action.

Pathophysiology and Rationale for Priority

The hyperinflammatory state in KD can lead to a recalcitrant disease course, as noted in recent cohort analyses [4]. The vasculitis damages the vessel wall, causing endothelial dysfunction and weakening of the arterial wall structure. This can result in dilatation or aneurysm formation. A scientific statement from the American Heart Association emphasizes the critical need for targeted ischemic testing in pediatric patients with conditions like KD that involve coronary aneurysms, highlighting the high priority of detecting coronary involvement [1]. The risk is especially pronounced in specific populations; a recent study found that among infants with KD and BCG site reactivation, an overwhelming 83.3% developed CAAs [3]. This underscores that the cardiac threat is not merely theoretical but a common and severe reality, particularly in younger children. Monitoring for signs of cardiac complications, such as arrhythmias, tachycardia out of proportion to fever, gallop rhythm, or signs of myocardial infarction, directly addresses this life-threatening risk. Administering aspirin (Option 1), providing comfort measures for the rash (Option 2), and encouraging fluids (Option 4) are all important but are secondary to the continuous assessment of cardiovascular stability and early detection of myocardial compromise.

Analysis of Incorrect Options

- Option 1: Administering aspirin is a core treatment in KD for its anti-inflammatory (high-dose) and antiplatelet (low-dose) effects. However, it is a medical intervention that follows a provider's prescription and is not the nurse's highest independent priority assessment in the acute phase. The nurse must first assess the patient's response and monitor for the very complications the aspirin aims to prevent.

- Option 2: Applying cool compresses is a comfort measure for the polymorphous rash. While addressing skin integrity and discomfort is a valid nursing concern, it does not address a life-threatening complication. The rash, though distressing, is a self-limiting symptom of the underlying vasculitis and does not pose the same immediate danger as coronary artery damage.

- Option 4: Encouraging fluid intake is essential due to prolonged fever and the risk of dehydration. Maintaining hydration status is a fundamental nursing responsibility. However, in the hierarchy of physiological needs, the risk of acute cardiac decompensation from coronary artery thrombosis or rupture takes absolute precedence over the more manageable risk of dehydration.

Application to Clinical Practice

The NCLEX-RN frequently tests the concept of "highest priority" using Maslow's hierarchy and the ABC (Airway, Breathing, Circulation) framework. In this scenario, the risk of coronary artery aneurysm directly threatens the "Circulation" component. A bibliometric analysis of KD literature confirms that the global research focus is overwhelmingly on cardiovascular complications, reflecting their clinical significance . When caring for a child with KD, the nurse's primary surveillance must center on the cardiovascular system: continuous cardiac monitoring, frequent auscultation for murmurs or gallops, and meticulous observation for signs of myocardial ischemia or heart failure. This anticipatory vigilance is the most critical independent nursing function to prevent catastrophic outcomes during the acute phase of Kawasaki disease.References (research sources)

- [1]Multimodality Approach to Coronary Ischemic Testing in Pediatric Patients: A Scientific Statement From the American Heart Association.Research articleOlivieri LJ, Lee S, Chen MH, Dahdah N, Doan TT, Jegatheeswaran A, Krishnamurthy R, Selamet Tierney ES, Weber EM, Rao A, American Heart Association Council on Lifelong Congenital Heart Disease and Heart Health in the Young, and the Council on Cardiovascular and Stroke Nursing. (2026) · DOI: 10.1161/jaha.125.047790

- [3]Coronary artery abnormalities in Kawasaki disease with BCG site reactivation.Research articlePilania RK, Thangaraj A, Loganathan S, Desai D, Kv A, Thakur V, Dhaliwal M, Sharma S, Jindal AK, Vignesh P, Suri D, Rawat A, Manphool Singhal, Singh S. (2025) · DOI: 10.1007/s00431-025-06709-1

- [4]Predicting recalcitrant hyperinflammatory disease course in children with Kawasaki disease and MIS-C.Research articleSatirer Ö, Eroglu FK, Nordmeyer J, Kumpf M, Neunhoeffer F, Icheva V, Reiser C, Buzoianu O, Benseler SM, Kuemmerle-Deschner JB. (2026) · DOI: 10.1186/s12969-026-01206-7

## 임상 시나리오

Clinical Priority: Kawasaki Disease

In the acute phase of Kawasaki disease, the highest priority nursing action is continuous cardiac monitoring. The systemic vasculitis targets the coronary arteries, and the development of aneurysms is the most significant determinant of long-term morbidity and mortality.

Key Assessment Focus

- Place the child on a cardiac monitor and assess rhythm for signs of myocarditis, ischemia, or arrhythmias.

- Obtain a baseline echocardiogram and serial follow-ups as ordered to evaluate for coronary artery dilatation or aneurysms.

- Closely monitor vital signs, noting any signs of heart failure such as tachycardia, gallop rhythm, or respiratory distress.

Clinical Reasoning

While administering aspirin, providing comfort measures, and maintaining hydration are all important components of care, they are secondary to the early detection of life-threatening cardiac complications. A child can decompensate rapidly from myocardial ischemia or arrhythmia, making vigilant monitoring the immediate priority.

## 핵심 개념

- **Kawasaki disease** — An acute systemic vasculitis of unknown etiology primarily affecting children under 5, with a predilection for coronary arteries.
- **Coronary artery aneurysm** — A pathological dilatation of a coronary artery segment, the most serious complication of Kawasaki disease, which can lead to thrombosis, myocardial infarction, or sudden death.
- **Acute phase of Kawasaki disease** — The initial stage (days 1-11) characterized by high fever, conjunctival injection, oral changes, rash, and cervical lymphadenopathy, where inflammation peaks.

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