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 A
Explanation
A. While monitoring for increased intracranial pressure is important, measuring head circumference every shift may not be necessary unless there is a specific indication or change in the child's condition.
B. Admitting the child to a private room is necessary to reduce the risk of spreading the infection to others.
C. Placing the child in a semi-Fowler's position can help reduce intracranial pressure and promote comfort.
D. Implementing seizure precautions is important, as children with bacterial meningitis are at risk for seizures.
Correct Answer is A
Explanation
A. Body weight is the most reliable indicator of fluid loss in an infant. Changes in weight can reflect changes in fluid balance more accurately than other parameters.
B. Blood pressure may be affected by severe dehydration, but it is not as sensitive or specific as changes in body weight.
C. Skin integrity can be affected by dehydration, but it is not as direct a measure of fluid loss as changes in body weight.
D. Respiratory rate can be influenced by various factors, including respiratory distress, and is not as specific to fluid loss as changes in body weight.
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