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 C
Explanation
Choice A reason: This is incorrect because seizure precautions are not indicated for dopamine administration. Dopamine does not lower the seizure threshold or cause convulsions.
Choice B reason: This is incorrect because monitoring serum potassium frequently is not necessary for dopamine administration. Dopamine does not affect potassium levels or cause hyperkalemia or hypokalemia.
Choice C reason: This is correct because ensuring pump accuracy to prevent toxicity is essential for dopamine administration. Dopamine is a potent vasoconstrictor that can cause tissue necrosis, gangrene, and hypertension if overdosed.
Choice D reason: This is incorrect because measuring urinary output every hour is not sufficient for dopamine administration. Dopamine can cause oliguria or anuria due to renal vasoconstriction and decreased renal perfusion. The nurse should monitor urine output continuously and report any decrease to the provider.
Correct Answer is C
Explanation
Choice A reason: Remove the catheter and palpate the client's bladder for residual distention. This is not the best action, as it may cause discomfort and trauma to the client. The catheter should not be removed until the bladder is fully emptied or up to 1,000 mL of urine is drained, as removing it too soon may cause urinary retention or infection.
Choice B reason: Remove the catheter and replace with an indwelling catheter. This is not the best action, as it may cause unnecessary exposure and trauma to the client. The catheter should not be replaced unless ordered by the healthcare provider, as replacing it may increase the risk of infection or urethral injury.
Choice C reason: Allow the bladder to empty completely or up to 1,000 mL of urine. This is the best action, as it can prevent bladder spasms, overdistention, or rupture. The nurse should monitor the urine output and color, and document the amount and characteristics of urine drained.
Choice D reason: Clamp the catheter for thirty minutes and then resume draining. This is not the best action, as it may cause pain and discomfort to the client. The catheter should not be clamped unless ordered by the healthcare provider, as clamping it may increase the risk of infection or bladder damage.
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