A preschool-aged child who is being treated for Streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding provides the earliest indication to the nurse that the child is experiencing a reaction to the toxins that are created by the Streptococcus bacteria?

Flaky, peeling skin.

Red bumps across chest.

White coating on tongue.

High, protracted fever.

Answer and Explanation

The Correct Answer is B

A. Flaky, peeling skin (desquamation) occurs in later stages of scarlet fever, typically after the rash begins to fade. It is not an early sign of the disease.
B. A red, sandpaper-like rash that typically begins on the chest and spreads outward is one of the earliest indications of scarlet fever. This rash is caused by exotoxins produced by Streptococcus pyogenes and is a hallmark sign of the illness.
C. A white coating on the tongue, often followed by a characteristic “strawberry tongue,” develops later in the progression of scarlet fever rather than as an early symptom.
D. While fever is a common symptom of streptococcal infections, it is not the earliest indicator of scarlet fever. The rash usually appears within 12 to 48 hours of fever onset, making it a more specific early sign.

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Correct Answer is B

Explanation

A. While the refusal to eat is concerning, it does not pose an immediate risk to the client's safety.
B. The situation involving the 18-year-old client could escalate quickly and poses an immediate risk to the client's and others' safety, requiring prompt intervention.
C. Pacing may indicate agitation or anxiety; however, it does not require immediate intervention unless it escalates.
D. Refusal to participate in group therapy is a concern for the client's treatment but does not pose an immediate risk to their safety.

A. Recommend the use of support stockings to enhance venous return. B. Ensure the client receives frequent small meals containing complete proteins. C. Evaluate patency of the AV graft for resumption of hemodialysis D. Instruct the client to continue to follow the prescribed rigid fluid restriction amounts.

Correct Answer is B

Explanation

A. Support stockings may help with peripheral edema, but they do not address the underlying issue of hypoalbuminemia and its consequences.
B. Adequate protein intake is crucial for increasing serum albumin levels, which can help reduce edema and improve the client's nutritional status. This intervention addresses the root cause of
the client's symptoms.

C. Evaluating the patency of the AV graft is important for long-term planning of hemodialysis access, but it is not the immediate priority given the client's current nutritional status and symptoms.
D. Fluid restriction is important in managing peritoneal dialysis patients, but it does not address the immediate concern of hypoalbuminemia and its effects on the client's health.

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A preschool-aged child who is being treated for Streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding provides the earliest indication to the nurse that the child is experiencing a reaction to the toxins that are created by the Streptococcus bacteria?

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Naxlex Comprehensive Predictor Exams

The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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