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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Applying a pressure dressing four hours after discharge is not typically recommended following a cardiac catheterization. The site of the catheter insertion is usually covered with a simple dressing and observed for any signs of bleeding or swelling.
Choice B rationale
While it’s important to monitor for signs of impaired circulation, such as a cool extremity, this is not the primary concern following a cardiac catheterization. The procedure involves inserting a catheter into a blood vessel, not typically affecting the peripheral temperature of the extremities.
Choice C rationale
Administering acetaminophen or ibuprofen for pain as needed is a common recommendation following procedures like a balloon angioplasty. Pain can result from the catheter insertion site and these medications can help manage it.
Choice D rationale
Maintaining a clear liquid diet for 24 hours after discharge is not typically necessary following a cardiac catheterization. Once the child is alert, they are usually provided with clear liquids and later something to eat.
Correct Answer is C
Explanation
Choice A rationale
Terbutaline does not typically cause a decrease in maternal blood glucose levels. It is a medication used to relax the muscles in the uterus to prevent premature labor.
Choice B rationale
Terbutaline does not enhance the production of fetal lung surfactant. It is used to relax the muscles in the uterus to prevent premature labor.
Choice C rationale
Weakened uterine contractions are an expected finding in a client who has received terbutaline. Terbutaline is a tocolytic medication, which means it works to inhibit uterine contractions in order to prevent or halt preterm labor.
Choice D rationale
Terbutaline does not typically cause a decrease in fetal heart rate. It is used to relax the muscles in the uterus to prevent premature labor.
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