A nurse is attending to an 8-year-old child diagnosed with acute rheumatic fever. What should be the nurse’s immediate priority assessment after admission?

Identifying the level of parental anxiety related to the diagnosis

Auscultating the rate and characteristics of the child’s heart sounds

Using a pain-rating tool to evaluate the severity of the joint pain

Assessing the client’s erythematous rash

Answer and Explanation

The Correct Answer is B

Choice A rationale
While it’s important to assess the level of parental anxiety related to the diagnosis, it’s not the immediate priority. The child’s physical health needs to be stabilized first.
Choice B rationale
This is the correct answer. Auscultating the rate and characteristics of the child’s heart sounds is the immediate priority. Acute rheumatic fever can lead to serious cardiac complications, so it’s crucial to monitor the child’s heart function closely.
Choice C rationale
While assessing the severity of joint pain is important in managing the child’s comfort, it’s not the immediate priority. The child’s heart function needs to be assessed first.
Choice D rationale
While assessing the client’s erythematous rash is part of the overall assessment of a child with acute rheumatic fever, it’s not the immediate priority. The child’s heart function needs to be assessed first.

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Correct Answer is ["C","D","E"]

Explanation

Choice A rationale
A newborn born at 32 weeks of gestation and weighing 1,100 g is considered preterm and is likely to have a thin, fragile appearance rather than a plump face.
Choice B rationale
Dehydration is not a typical finding in a preterm newborn unless there are underlying health issues or complications.
Choice C rationale
Long nails are a common finding in preterm newborns. This is because nail growth begins in the womb and preterm babies have had less time to wear down their nails through movement.
Choice D rationale
A weak grasp reflex is common in preterm newborns. This is due to their immature nervous system.
Choice E rationale
The presence of lanugo, or fine hair, is common in preterm newborns. Lanugo usually begins to disappear around 32 weeks of gestation, so a baby born at this time may still have a significant amount.

A. Infective endocarditis B. Kawasaki disease C. Hypoplastic left heart syndrome D. Cardiomyopathy E. Transposition of the great vessels

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale
Infective endocarditis is an infection of the inner lining of the heart’s chambers or valves. It’s typically caused by bacteria entering the blood and settling in the heart. It is considered an acquired heart disease because it develops during a person’s lifetime.
Choice B rationale
Kawasaki disease is an illness that causes inflammation in arteries, veins, and capillaries. It’s most common in children younger than 5 years old. While it’s not a heart disease, it can lead to serious heart problems if not treated.
Choice C rationale
Hypoplastic left heart syndrome is a type of congenital heart defect, meaning it’s present at birth. Therefore, it’s not considered an acquired heart disease.
Choice D rationale
Cardiomyopathy is a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body. It can be acquired or inherited.
Choice E rationale
Transposition of the great vessels is a serious but rare heart defect present at birth (congenital), in which the two main arteries leaving the heart are reversed (transposed). Therefore, it’s not considered an acquired heart disease.

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A nurse is attending to an 8-year-old child diagnosed with acute rheumatic fever. What should be the nurse’s immediate priority assessment after admission?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the assessment of a newborn who was born at 32 weeks of gestation. The newborn’s birth weight is 1,100 g. What are the expected findings in this newborn? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

Which of the following heart diseases are considered acquired? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

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A nurse is attending to an 8-year-old child diagnosed with acute rheumatic fever. What should be the nurse’s immediate priority assessment after admission?