A nurse is caring for an 8-year-old child who has acute rheumatic fever. Which of the following assessments is the nurse's priority immediately after admission?
Using a pain-rating tool to determine the severity of the joint pain
Assessing the client's erythematous rash
Identifying the degree of parental anxiety related to the diagnosis
Auscultating the rate and regularity of the child's heart sounds and notifying the provider immediately of abnormalities
The Correct Answer is D
Choice A: Using a pain-rating tool to determine the severity of the joint pain is not the priority assessment for an 8-year-old child who has acute rheumatic fever, which is an inflammatory condition that can affect various organs, especially the heart, joints, skin, and brain. Joint pain is one of the major criteria for diagnosing acute rheumatic fever and can affect one or more large joints, such as knees, ankles, elbows, or wrists. Joint pain can be managed with analgesics or anti-inflammatory drugs.
Choice B: Assessing the client's erythematous rash is not the priority assessment for an 8-year-old child who has acute rheumatic fever, which is an inflammatory condition that can affect various organs, especially the heart, joints, skin, and brain. The erythematous rash is one of the minor criteria for diagnosing acute rheumatic fever and can appear as pink or red patches on the trunk or limbs. The erythematous rash can fade or change location over time and does not require any specific treatment.
Choice C: Identifying the degree of parental anxiety related to the diagnosis is not the priority assessment for an 8-year-old child who has acute rheumatic fever, which is an inflammatory condition that can affect various organs, especially the heart, joints, skin, and brain. Parental anxiety related to the diagnosis can affect their coping skills and ability to care for their child. Parental anxiety can be addressed by providing education, support, and referral to appropriate resources.
Choice D: Auscultating the rate and regularity of the child's heart sounds and notifying the provider immediately of abnormalities is the priority assessment for an 8-year-old child who has acute rheumatic fever, as it can indicate cardiac involvement, which is the most serious complication of acute rheumatic fever. Cardiac involvement can cause damage to the heart valves, myocardium, or pericardium and lead to heart failure or death. Abnormalities in heart sounds may include murmurs, rubs, gallops, or arrhythmias.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Shingles is a viral infection that causes a painful rash, usually on one side of the body. It is caused by the same virus that causes chickenpox. Shingles is not related to tinea pedis, which is a fungal infection.
Choice B: Valley fever is a fungal infection that affects the lungs and can cause flu-like symptoms, such as fever, cough, and chest pain. It is caused by inhaling spores from a fungus that grows in dry soil. Valley fever is not related to tinea pedis, which affects the skin of the feet.
Choice C: Athlete's foot is a common name for tinea pedis, which is a fungal infection that affects the skin between the toes and on the soles of the feet. It can cause itching, burning, scaling, and cracking of the skin. Athlete's foot is contagious and can be spread by direct contact or by sharing shoes, socks, or towels.
Choice D: Fever blister is another name for a cold sore, which is a small blister that forms on or near the lips. It is caused by a type of herpes virus that can be transmitted by kissing or sharing utensils. Fever blister is not related to tinea pedis, which is a fungal infection.
Correct Answer is B
Explanation
Choice A: This instruction is not correct, as the child should avoid taking a tub bath for the first 3 days after a cardiac catheterization, which is a procedure that involves inserting a thin tube into a blood vessel and advancing it to the heart to diagnose or treat heart problems. Taking a tub bath can increase the risk of infection or bleeding at the insertion site, which is usually in the groin or arm. The child should take a shower instead and keep the insertion site clean and dry.
Choice B: This instruction is correct, as the child may experience some discomfort or soreness at the insertion site after a cardiac catheterization. Giving the child acetaminophen can help relieve the pain and reduce inflammation. The child should avoid taking aspirin or ibuprofen, as they can increase the risk of bleeding.
Choice C: This instruction is not correct, as the child does not need to stay home for 1 week after a cardiac catheterization unless there are complications or specific instructions from the provider. The child can resume normal activities within 2 to 3 days after the procedure, as long as they avoid strenuous exercise, heavy lifting, or contact sports.
Choice D: This instruction is not correct, as the child does not need to limit their diet to clear liquids for the first 24 hours after a cardiac catheterization unless there are complications or specific instructions from the provider. The child can resume their regular diet as soon as they feel hungry and drink plenty of fluids to flush out the contrast dye used during the procedure.
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