# A 3-year-old child is admitted with suspected Kawasaki disease. Which assessment finding would be most concerning and require immediate nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541980 > language: ko > subject: Infectious Diseases ## 문제 A 3-year-old child is admitted with suspected Kawasaki disease. Which assessment finding would be most concerning and require immediate nursing intervention? ## 보기 1. Bilateral conjunctival injection without exudate 2. Strawberry tongue with cracked, dry lips 3. Polymorphous rash on trunk and extremities 4. New onset of chest pain with decreased activity tolerance **✔ 정답** **정답: 4** ## 해설 New onset chest pain with decreased activity tolerance indicates potential coronary artery involvement, the most serious complication requiring immediate intervention. Other options are typical Kawasaki disease findings not immediately life-threatening. ## 심화 해설 Clinical Reasoning and Priority Setting The correct answer is 4. New onset of chest pain with decreased activity tolerance. In a child with suspected Kawasaki disease (KD), this finding is the most concerning because it signals potential myocardial ischemia or infarction, which is the most serious acute complication of the disease. Differentiating Expected from Critical Findings Kawasaki disease is a pediatric hyperinflammatory disorder characterized by systemic vasculitis, with a particular predilection for the coronary arteries [3]. The classic diagnostic criteria include several mucocutaneous findings that, while striking, are expected in the disease course and do not independently signal a life-threatening emergency. The first three options represent these classic, expected clinical features: - Bilateral conjunctival injection without exudate is a hallmark finding, present in the vast majority of cases. - Strawberry tongue with cracked, dry lips reflects the characteristic oral mucosal changes. - A polymorphous rash on the trunk and extremities is a common dermatologic manifestation, though the presentation can be highly heterogeneous [2]. While these findings support the diagnosis of KD, they do not require immediate, life-saving intervention beyond initiating therapy. The Priority: Coronary Artery Complications The primary clinical concern in the acute and subacute phases of KD is the development of coronary artery aneurysms and subsequent myocardial dysfunction [3]. The vasculitis can lead to weakening of the arterial wall, aneurysm formation, and a pro-thrombotic state, placing the child at high risk for myocardial infarction. A new report of chest pain with decreased activity tolerance is a classic anginal equivalent in a young child. This clinical presentation is highly suggestive of myocardial ischemia. As demonstrated in long-term follow-up cases, even patients with a remote history of KD who report only atypical chest pain or slight dyspnea on exertion can harbor significant, hemodynamically relevant coronary stenosis that requires urgent intervention like angioplasty [1]. In the acute setting, such a symptom demands immediate assessment, continuous cardiac monitoring, a 12-lead ECG, and prompt notification of the provider to prevent irreversible myocardial damage. The nurse's priority is recognizing that this symptom represents a potential progression from vasculitis to a critical ischemic event.References (research sources) - [1]Case Report: Late coronary complication of Kawasaki disease.Case reportBucher I, Cook S, Brahim Mathiron A. (2025) · DOI: 10.3389/fped.2025.1527714 - [2]Cutaneous Clues in Kawasaki Disease: Clinical Implications and Differential Diagnosis with Multisystem Inflammatory Syndrome in Children.Research articleCarlini F, Chiesa AM, Verzina M, Sassetti C, Rigante D, Esposito S. (2026) · DOI: 10.3390/jcm15031126 - [3]Advancing multidisciplinary management of pediatric hyperinflammatory disorders.Research articleLa Torre F, Meliota G, Civino A, Campanozzi A, Cecinati V, Rosati E, Sacco E, Santoro N, Vairo U, Cardinale F. (2025) · DOI: 10.3389/fped.2025.1553861 ## 임상 시나리오 Clinical Priority in Kawasaki Disease A 3-year-old with suspected Kawasaki disease develops new-onset chest pain and decreased activity tolerance. This case highlights the critical distinction between expected diagnostic findings and life-threatening complications requiring immediate intervention. Immediate Assessment - **Cardiac Monitoring:** Initiate continuous cardiac monitoring and obtain a 12-lead ECG to assess for ST-segment changes, T-wave abnormalities, or arrhythmias indicative of myocardial ischemia. - **Echocardiogram:** An urgent echocardiogram is essential to evaluate for coronary artery dilation or aneurysms, left ventricular function, and valvular regurgitation. - **Vital Signs and Perfusion:** Assess for hypotension, tachycardia, gallop rhythm, or signs of poor peripheral perfusion, which may signal cardiogenic shock. Nursing Interventions - **Notify the Provider:** Immediately report the change in condition to the pediatrician or pediatric cardiologist. Chest pain in this context is a potential precursor to myocardial infarction. - **Administer IVIG:** If not already initiated, prepare for high-dose intravenous immunoglobulin (IVIG) administration, the cornerstone of treatment to reduce coronary artery complications. - **Adjunct Therapy:** Administer high-dose aspirin as ordered for its anti-inflammatory and antiplatelet effects during the acute phase. - **Pain Management:** Address chest pain with appropriate analgesics while avoiding agents that may mask cardiac symptoms without addressing the underlying vasculitis. Differentiating Expected from Critical Findings - **Expected Findings (Do Not Require Immediate Intervention):** Bilateral conjunctival injection without exudate, strawberry tongue with cracked lips, and polymorphous rash are classic diagnostic criteria. They support the diagnosis but are not acutely life-threatening. - **Critical Finding (Requires Immediate Intervention):** Chest pain with decreased activity tolerance is a red flag for myocardial ischemia or infarction secondary to coronary artery vasculitis or aneurysm thrombosis. Ongoing Monitoring - Serial echocardiograms are typically performed at diagnosis, 2 weeks, and 6-8 weeks post-treatment to monitor coronary artery status. - Monitor for signs of heart failure, including respiratory distress, hepatomegaly, and edema. - Educate the family that irritability and decreased activity in a previously active child can be an anginal equivalent in this age group. ## 핵심 개념 - **Kawasaki Disease** — An acute, self-limited vasculitis of childhood characterized by fever and mucocutaneous findings, with a predilection for coronary arteries. - **Coronary Artery Aneurysm** — A pathological dilation of a coronary artery segment, the most serious complication of Kawasaki disease, which can lead to myocardial ischemia or infarction. - **Myocardial Ischemia** — A condition of reduced blood flow and oxygen supply to the heart muscle, often presenting as chest pain, and a critical finding in Kawasaki disease. - **Conjunctival Injection** — Redness of the conjunctiva; in Kawasaki disease, it is typically bilateral and without exudate, serving as a key diagnostic criterion. - **Strawberry Tongue** — An oral manifestation where the tongue appears red and bumpy due to prominent fungiform papillae, commonly seen in Kawasaki disease and scarlet fever. ## 같은 주제 문제 - [A 3-year-old child is admitted to the pediatric unit with a 5-day history of high fever. 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