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A nurse is caring for an 8-year-old client who has been diagnosed with acute rheumatic fever. Which action is the nurse's priority for a client with this presentation?

Reviewing the client's complete blood count (CBC).

Using a pain-rating tool to determine the severity of the joint pain.

Assessing the client's erythematous rash.

Auscultating the rate and characteristics of the child's heart sounds.

Answer and Explanation

The Correct Answer is D

A. While reviewing the CBC is important, it is not the priority.

B. Assessing joint pain is necessary for managing symptoms, but it is not the most critical initial action.

C. Evaluating the erythematous rash is part of the assessment, but it does not take precedence.

D. Auscultating the heart is the priority because acute rheumatic fever can lead to carditis, which can cause significant and potentially life-threatening heart complications. Early detection of abnormal heart sounds is crucial.

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Correct Answer is D

Explanation

A. Applying topical diphenhydramine may help with local itching but is not the priority in a child with a known allergy to insect stings.

B. A cool pack can reduce swelling but is not the priority action if an allergic reaction is suspected.

C. Positioning the child with legs elevated is appropriate if there are signs of shock but does not address the immediate risk of airway compromise.

D. Assessing the client's airway and breathing rate is the priority because a child with a known allergy to insect stings is at risk for anaphylaxis, which can cause airway obstruction and respiratory distress. Early recognition and intervention are critical.

A. Low-fat yogurt with blueberries and granola B. Cheese, banana slices, rice cakes, and whole milk C. Eggs, bacon, rye toast, and lactose-free milk D. Egg, cheese, and sausage wrapped in a flour tortilla

Correct Answer is B

Explanation

A. Granola often contains gluten, so this meal would not be suitable for someone with celiac disease.

B. Cheese, banana slices, rice cakes, and whole milk are gluten-free and appropriate for a child with celiac disease.

C. Rye toast contains gluten, which is contraindicated for someone with celiac disease.

D. Flour tortillas generally contain gluten, so this meal is not appropriate for someone with celiac disease.

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A nurse is caring for an 8-year-old client who has been diagnosed with acute rheumatic fever. Which action is the nurse's priority for a client with this presentation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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