A nurse is assisting with the admission of a 9-year-old child who has acute rheumatic fever. When obtaining the client's history, it is appropriate for the nurse to ask the parent which of the following questions?
"Has your son had a sore throat recently?"
"Was your son born with this cardiac defect?"
"Are you aware that your son will have to be in isolation?
"Has your child had any injuries recently?"
The Correct Answer is A
A. "Has your son had a sore throat recently?"
This question is relevant because acute rheumatic fever often occurs as a complication of untreated or inadequately treated streptococcal throat infection (strep throat). A recent history of sore throat could indicate a preceding streptococcal infection, which is an important predisposing factor for the development of acute rheumatic fever.
B. "Was your son born with this cardiac defect?"
This question is less relevant in the context of acute rheumatic fever. Acute rheumatic fever is not a congenital heart defect; it is an inflammatory condition that affects the heart valves following streptococcal infection. While it's important to assess the child's cardiac health, asking about congenital heart defects may not directly relate to the current condition.
C. "Are you aware that your son will have to be in isolation?"
This question is not applicable to acute rheumatic fever. Acute rheumatic fever is not a contagious condition that requires isolation. It is an autoimmune response triggered by streptococcal infection and does not pose a risk of transmission to others.
D. "Has your child had any injuries recently?"
Inquiring about recent injuries is not directly related to acute rheumatic fever. Acute rheumatic fever is an inflammatory condition primarily triggered by streptococcal infection and is not caused by physical injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I will elevate the affected area if possible."
This statement is correct. Elevating the affected area can help reduce swelling and minimize bleeding by promoting venous return. Elevating the limb above the level of the heart can aid in controlling bleeding and is a recommended intervention.
B. "I will apply warm compresses over the site."
This statement is incorrect. Applying warm compresses is generally not recommended for controlling bleeding in hemophilia. Heat can increase blood flow to the area, potentially exacerbating bleeding. Cold compresses or ice packs are typically recommended to help constrict blood vessels and reduce bleeding.
C. "I will have my child rest."
This statement is correct. Resting is an essential component of managing bleeding episodes in children with hemophilia. Physical activity and exertion can increase the risk of injury and bleeding, so it's important for children with hemophilia to avoid strenuous activities during bleeding episodes.
D. "I will promptly mobilize the involved area to relieve pain & decrease bleeding."
Immobilizing the affected area can help control bleeding and reduce pain by minimizing movement. This is also an appropriate response.
Correct Answer is A
Explanation
A. Apical:
The apical pulse is the most reliable location to assess the pulse in infants. It is located at the apex of the heart, which is typically found at the fifth intercostal space at the midclavicular line. Assessing the apical pulse allows for a direct measure of the heart rate and rhythm, which is especially important in infants to evaluate cardiac function accurately. The apical pulse is commonly assessed using a stethoscope placed at the point of maximum impulse (PMI) on the chest.
B. Dorsalis pedis:
The dorsalis pedis pulse is located on the top of the foot, typically in the region between the first and second metatarsal bones. While the dorsalis pedis pulse can be palpated in older children and adults, it may be difficult to palpate accurately in infants, especially those with smaller or more delicate feet. Therefore, it is not the preferred site for pulse assessment in infants.
C. Temporal:
The temporal pulse is located on the side of the head, just above the ear. While the temporal pulse can be palpated in some individuals, it is not typically used to assess the pulse in infants. Palpating the temporal pulse in infants may be more challenging and less reliable compared to other pulse sites, especially given the smaller size of the temporal artery in infants.
D. Carotid:
The carotid pulse is located in the neck, alongside the trachea, and can be palpated by gently pressing the fingers against the carotid artery. While the carotid pulse is easily palpable in adults and older children, it is not typically the preferred site for pulse assessment in infants. Palpating the carotid pulse in infants carries a risk of injury to the delicate structures in the neck and may not provide an accurate representation of the pulse rate.
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