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 A
Explanation
Choice A rationale
Practicing Kegel exercises is a common recommendation for postpartum women experiencing urinary incontinence. Kegel exercises strengthen the pelvic floor muscles, which support the uterus, bladder, small intestine, and rectum. Strengthening these muscles can help control urinary incontinence.
Choice B rationale
Abdominal crunches are not typically recommended for postpartum women, especially those who have had a cesarean birth. These exercises can strain the abdominal muscles and may interfere with the healing process.
Choice C rationale
Similar to abdominal crunches, sit-ups are not typically recommended for postpartum women, especially those who have had a cesarean birth. These exercises can strain the abdominal muscles and may interfere with the healing process.
Choice D rationale
While pelvic tilt exercises can be beneficial for postpartum women, they are not specifically targeted at improving urinary incontinence.
Correct Answer is A
Explanation
Choice A rationale
Acute rheumatic fever is a complication that can occur after an infection with group A streptococcus, which causes strep throat and sometimes scarlet fever. The most common symptoms of rheumatic fever include fever, painful and tender joints, pain in the chest, fatigue, fast heart rate, palpitations, and multiple-joint inflammation. Therefore, asking if the child has had a sore throat recently is relevant as it could indicate a recent strep throat infection, which is a common precursor to acute rheumatic fever.
Choice B rationale
While injuries can lead to various health complications, they are not directly related to the development of acute rheumatic fever. Acute rheumatic fever is primarily caused by an overreaction of the body’s immune system to a strep throat or scarlet fever infection.
Therefore, recent injuries would not typically be a relevant factor in a suspected case of acute rheumatic fever.
Choice C rationale
Acute rheumatic fever is not a congenital condition, meaning it is not present from birth. It develops as a complication of strep throat or scarlet fever. Therefore, asking if the child was born with a cardiac defect would not typically be relevant in a suspected case of acute rheumatic fever.
Choice D rationale
While aspirin is often used in the treatment of rheumatic fever to reduce inflammation and pain, it is not a cause of the condition. Therefore, asking if the child has been given aspirin in the past 2 weeks would not typically be relevant in a suspected case of acute rheumatic fever.
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