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 B
Explanation
Choice A rationale
Iron supplements should not be administered in one large dose every day. High doses can cause side effects such as nausea, vomiting, diarrhea, constipation, and dark stools.
Choice B rationale
Monitoring blood count routinely for several weeks is necessary when a child is taking iron supplements for iron deficiency anemia. This helps to ensure that the supplement is effective and that iron levels are being restored to a healthy range.
Choice C rationale
Iron supplements are not necessarily more effective if administered with meals. In fact, some studies suggest that taking iron supplements with food might decrease the amount of iron absorbed.
Choice D rationale
Restricting fiber from a child’s diet will not necessarily help with the absorption of iron. In fact, a balanced diet, including fiber, is important for overall health.
Correct Answer is A
Explanation
Choice A rationale
A newborn’s heart rate normally varies between 120 and 160 beats per minute, but it can rise to 180 beats per minute when the infant is crying or drop as low as 80 to 90 beats per minute when in deep sleep. Therefore, an apical heart rate of 130/min is within the normal range for a newborn.
Choice B rationale
There is no need to call the provider for further assessment if the newborn’s heart rate is within the normal range.
Choice C rationale
Preparing the newborn for transport to the NICU is not necessary if the heart rate is within the normal range.
Choice D rationale
Asking another nurse to verify the heart rate is not necessary if the heart rate is within the normal range.
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