# A 3-year-old child is admitted to the pediatric unit with suspected Kawasaki disease. Which assessment finding would be most concerning and require immediate nursing intervention?

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## 문제

A 3-year-old child is admitted to the pediatric unit 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 the trunk and extremities
4. New onset of chest pain with decreased activity tolerance **✔ 정답**

**정답: 4**

## 해설

Chest pain with decreased activity tolerance indicates potential coronary artery involvement, the most serious complication of Kawasaki disease requiring immediate cardiac monitoring and intervention. Other options are typical diagnostic findings but do not signify acute cardiac compromise.

## 심화 해설

Clinical Context & Priority Setting

This question presents a classic NCLEX-RN priority-setting scenario using the airway, breathing, circulation (ABC) framework combined with knowledge of disease-specific complications. Kawasaki disease (KD) is an acute systemic vasculitis that predominantly affects medium-sized arteries, and it is the leading cause of acquired heart disease in children in developed countries [3]. While several clinical features define the diagnosis, the most serious long-term sequela is the development of coronary artery lesions (CALs), including aneurysms, which can lead to myocardial ischemia [1][2].

Therefore, when prioritizing care for a child with suspected KD, the nurse must first assess for signs of immediate, life-threatening cardiovascular complications. The other findings, while classic for KD, are expected manifestations of the acute inflammatory phase and do not signal an immediate threat to life.

Analysis of Options

- Option 1: Bilateral conjunctival injection without exudate — This is one of the principal diagnostic criteria for KD. It is an expected finding resulting from vasculitis of the small vessels in the conjunctiva. While it requires documentation and supportive care, it does not indicate a need for immediate intervention.

- Option 2: Strawberry tongue with cracked, dry lips — These are classic oral mucosal changes seen in the acute phase of KD. They are uncomfortable for the child and require supportive oral care, but they are not immediately dangerous and do not reflect a critical change in the patient’s status.

- Option 3: Polymorphous rash on the trunk and extremities — This is another common diagnostic criterion for KD. The rash is a manifestation of the underlying systemic inflammation. It is an expected finding that requires monitoring but no urgent intervention.

- Option 4: New onset of chest pain with decreased activity tolerance — This is the most concerning finding. In a child with suspected KD, new chest pain and a sudden decrease in activity tolerance are classic red flags for myocardial ischemia or infarction. This clinical picture suggests that coronary artery inflammation has progressed to a critical point, potentially causing thrombosis or significant stenosis within a coronary aneurysm. This finding signals an acute cardiac event and requires immediate nursing intervention, including notifying the provider, administering oxygen, obtaining an ECG, and preparing for transfer to a higher level of care.

Pathophysiology & Clinical Reasoning

The underlying pathology of KD is a systemic vasculitis with a strong tropism for the coronary arteries. The inflammatory process can lead to destruction of the arterial wall's structural integrity, resulting in dilation and aneurysm formation [1]. A validated composite of risk factors is used in clinical models to predict which children are at highest risk for developing these coronary artery lesions [2]. However, regardless of risk scores, the onset of symptoms suggestive of myocardial ischemia represents a failure of compensation and a direct threat to cardiac output. The nurse’s immediate recognition of this change from a stable, albeit ill, presentation to one of acute cardiac distress is the critical link in preventing a fatal outcome, which has been documented in cases of missed or delayed diagnosis [3].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

- [2]Prediction of Kawasaki disease coronary artery lesions in the Japan Environment and Children's Study.Research articleIwata H, Yamaguchi T, Tamura N, Bamai YA, Ikeda A, Itoh M, Yamamoto R, Tojo M, Ketema RM, Yamazaki K, Itoh S, Makino K, Shida S, Saijo Y, Ito Y, Kishi R, Japan Environment and Children’s Study Group. (2025) · DOI: 10.4103/apc.apc_71_25

- [3]Fatal incomplete Kawasaki disease in a six-month-old infant from Ethiopia: a case report : Author.Case reportHailegiorgies YT. (2026) · DOI: 10.1186/s12887-026-06753-2

## 임상 시나리오

Clinical Priority Rationale

In a child with suspected Kawasaki disease, the nurse's immediate priority is to assess for and intervene on life-threatening cardiovascular complications. Kawasaki disease is an acute systemic vasculitis with a predilection for the coronary arteries, making coronary artery lesions (including aneurysms) the most serious sequela. A new onset of chest pain with decreased activity tolerance is a cardinal sign of myocardial ischemia, which can progress to myocardial infarction. This finding takes precedence over the expected diagnostic criteria of the acute inflammatory phase, following the ABC (Airway, Breathing, Circulation) priority-setting framework.

Key Assessment Findings in Kawasaki Disease

- **Diagnostic Criteria (Expected Findings):** Bilateral conjunctival injection without exudate, polymorphous rash, oral mucosal changes (strawberry tongue, cracked lips), extremity changes (edema, erythema, desquamation), and cervical lymphadenopathy. These require supportive care and documentation but are not immediate emergencies.

- **Critical Finding (Complication):** Signs of myocardial ischemia, including chest pain, decreased activity tolerance, pallor, diaphoresis, or unexplained irritability in a young child. These warrant immediate notification of the provider, continuous cardiac monitoring, and preparation for an echocardiogram and potential interventions.

Nursing Actions for Suspected Cardiac Complication

- Immediately place the child on a cardiac monitor and obtain a full set of vital signs, including oxygen saturation.

- Perform a focused cardiovascular assessment, auscultating for murmurs, gallops, or a pericardial friction rub.

- Notify the healthcare provider of the change in status and anticipate orders for an urgent echocardiogram to evaluate for coronary artery dilation or aneurysms.

- Initiate intravenous access if not already established and prepare for possible administration of IV immunoglobulin (IVIG) and high-dose aspirin, which are the cornerstones of treatment to reduce coronary artery inflammation.

- Maintain a calm environment and cluster care to minimize myocardial oxygen demand.

Clinical Pearl

The greatest risk for coronary artery aneurysm development is during the subacute phase (weeks 2-4 of illness), but myocardial ischemia can occur at any point if there is significant coronary involvement or thrombosis. A high index of suspicion is critical, as young children may not verbalize classic chest pain; instead, they may present with new-onset lethargy, pallor, or inconsolable crying.

## 핵심 개념

- **Kawasaki disease** — An acute systemic vasculitis of unknown etiology primarily affecting medium-sized arteries, most commonly the coronary arteries, and the leading cause of acquired heart disease in children in developed countries.
- **Coronary artery aneurysm** — A potentially life-threatening complication of Kawasaki disease characterized by abnormal dilation of a coronary artery segment, which can lead to thrombosis, myocardial infarction, or rupture.
- **Myocardial ischemia** — A condition occurring when blood flow to the heart muscle is reduced, preventing it from receiving enough oxygen; in Kawasaki disease, this can result from coronary artery lesions or thrombosis.
- **ABC framework** — A priority-setting framework in nursing that stands for Airway, Breathing, and Circulation, used to identify and address the most immediately life-threatening patient needs first.

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