A nurse is caring for a child who has rheumatic fever. When obtaining the child's medical history from the parent, the nurse should recognize the significance of which of the following data as the possible source of the child's infection?
The father who had gastritis 2 weeks ago
A neighbor's child who has chickenpox
A sibling who had a sore throat 3 weeks ago
A classmate who has fifth disease
The Correct Answer is C
A. Gastritis is not an infectious condition and is unlikely to be the source of the child's rheumatic fever.
B. Chickenpox is caused by a different pathogen (varicella-zoster virus) and is not associated with the development of rheumatic fever.
C. Rheumatic fever often follows untreated or inadequately treated streptococcal infections, particularly streptococcal pharyngitis (sore throat). A sibling with a recent sore throat is a significant piece of information.
D. Fifth disease is caused by parvovirus B19 and is not known to be a precursor to rheumatic fever.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The radial artery is commonly used for assessing the pulse in older children and adults but is less reliable in infants.
B. The brachial artery is often used to measure blood pressure in infants, but it may not be as accurate for heart rate assessment.
C. The apex of the heart (apical pulse) is the preferred site for assessing the heart rate in infants.
It is located at the point of maximal impulse (PMI).
D. The carotid artery is typically not used for routine assessment of the heart rate in infants
Correct Answer is B
Explanation
A. Suctioning the nasopharynx as needed can help maintain airway patency but does not directly prevent aspiration during the recovery period.
B. Withholding fluids until the client demonstrates a gag reflex is a standard precaution to prevent aspiration, particularly in the immediate postoperative period.
C. Chest physiotherapy is not specifically indicated for preventing aspiration in the post- tonsillectomy period.
D. Placing a bedside humidifier at the head of the client's bed is not a specific intervention for preventing aspiration after tonsillectomy. Monitoring the client's ability to swallow and the return of the gag reflex is more relevant.
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