A preschool-aged child who is being tested for Streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding
provides the clearest indication to the nurse that the child is experiencing a reaction to toxins that are created by Streptococcal bacteria?
Flushed, peeling skin
Red bumps across chest
White coating on tongue
High, protracted fever
The Correct Answer is B
Choice A reason: Flushed, peeling skin is not a specific finding for scarlet fever. Flushed, peeling skin can be caused by various factors, such as sunburn, dehydration, allergic reaction, or infection. Scarlet fever is a condition that results from a Streptococcal infection in the throat or skin that produces toxins that cause a rash and fever. The rash usually begins on the neck and chest and then spreads to other parts of the body.
Choice B reason: This is the correct answer because red bumps across chest are a characteristic finding for scarlet fever. Red bumps across chest are part of the rash that develops due to toxins produced by Streptococcal bacteria. The rash usually feels like sandpaper and may be accompanied by itching or burning sensations. The rash typically lasts for about a week and then fades, leaving behind peeling skin.
Choice C reason: White coating on tongue is not a clear indication for scarlet fever. White coating on tongue can be caused by various factors, such as dehydration, poor oral hygiene, fungal infection, or inflammation. Scarlet fever may cause white patches or red spots on the tongue, but this is not a distinctive feature of scarlet fever.
Choice D reason: High, protracted fever is not a unique finding for scarlet fever. High, protracted fever can be caused by various factors, such as infection, inflammation, dehydration, or immunological disorder. Scarlet fever may cause high fever (above 101°F or 38.3°C), but this is not a definitive sign of scarlet fever.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack. This client does not require immediate attention, as refusing to eat is a common behavior for clients with anorexia nervosa. The nurse should monitor the client's nutritional intake and weight, and provide education and support.
Choice B reason: An 18-year-old client with antisocial behavior who is being yelled at by other clients. This client does not require immediate attention, as being yelled at by other clients is not a life-threatening situation. The nurse should intervene to maintain a safe and therapeutic environment, and set limits on the client's disruptive behavior.
Choice C reason: A 16-year-old client diagnosed with major depression who refuses to participate in group. This client does not require immediate attention, as refusing to participate in group is a common symptom of depression. The nurse should encourage the client to join the group, and offer individual counseling and medication as needed.
Choice D reason: A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby. This client requires immediate attention, as pacing around the lobby may indicate that the client is experiencing mania, which can lead to impulsivity, aggression, or self-harm. The nurse should assess the client's mood, behavior, and thought process, and administer medication as prescribed.
Correct Answer is C
Explanation
Choice A reason: An adolescent with multiple contusions due to a fall that occurred 2 days ago is not a client that the charge nurse should assign to the RN, as this is a stable and low-acuity client who can be safely cared for by the PN. This is a distractor choice.
Choice B reason: A 75-year-old client with renal calculi who requires urine straining is not a client that the charge nurse should assign to the RN, as this is a routine and non-complex task that can be performed by the PN. This is another distractor choice.
Choice C reason: A 30-year-old depressed client who admits to suicide ideation is a client that the charge nurse should assign to the RN, as this is an unstable and high-risk client who requires close monitoring, assessment, and intervention by the RN. Therefore, this is the correct choice.
Choice D reason: A 64-year-old client who had a total hip replacement the previous day is not a client that the charge nurse should assign to the RN, as this is a postoperative and moderate-acuity client who can be managed by the PN under the supervision of the RN. This is another distractor choice.
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