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?

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.

Choice A: Tachycardia is not a finding that indicates increased intracranial pressure, but rather a sign of shock, dehydration, or pain. Tachycardia is a fast heart rate, which is more than 160 beats per minute in infants. Tachycardia can occur when the body tries to compensate for low blood pressure, fluid loss, or tissue damage.

Choice B: Increased sleeping is a finding that indicates increased intracranial pressure, as it reflects altered level of consciousness, which is one of the earliest and most sensitive signs of increased intracranial pressure. Increased intracranial pressure can compress the brain tissue and affect its function and responsiveness. Increased sleeping can progress to lethargy, stupor, or coma.

Choice C: Brisk pupillary reaction to light is not a finding that indicates increased intracranial pressure, but rather a normal and expected response. A brisk pupillary reaction to light means that the pupils constrict quickly when exposed to bright light and dilate quickly when exposed to dim light. Brisk pupillary reaction to light indicates intact cranial nerve II (optic) and III (oculomotor).

Choice D: Depressed fontanels are not a finding that indicates increased intracranial pressure, but rather a sign of dehydration or malnutrition. Depressed fontanels are sunken or flat areas on the top or back of an infant's head where the skull bones have not yet fused together. Depressed fontanels can occur when there is insufficient fluid or tissue volume in the body.