The nurse is assessing a child admitted with a diagnosis of rheumatic fever. Which significant question would the nurse ask the child's parent during the assessment?
"Has your child been exposed to anyone with chicken pox
"Has any family member had a sore throat within the past few weeks?"
"Has any family member had a gastrointestinal disorder in the past few weeks?
"Has your child had difficulty urinating?
The Correct Answer is B
A. "Has your child been exposed to anyone with chicken pox?"
While chickenpox is caused by a different virus (varicella-zoster virus) and is not directly linked to rheumatic fever, the nurse might inquire about exposure to contagious illnesses as a general part of the assessment.
B. "Has any family member had a sore throat within the past few weeks?"
This question is relevant because rheumatic fever often follows an untreated or inadequately treated group A streptococcal infection, such as strep throat. A sore throat in a family member could indicate the presence of streptococcal infection, which is a crucial factor in the development of rheumatic fever.
C. "Has any family member had a gastrointestinal disorder in the past few weeks?"
Gastrointestinal disorders are not directly associated with the development of rheumatic fever. However, a comprehensive medical history might include questions about recent illnesses to understand the overall health context.
D. "Has your child had difficulty urinating?"
Difficulty urinating is not a typical symptom or risk factor associated with rheumatic fever. This symptom would likely prompt investigation into other potential issues but is not specifically related to rheumatic fever.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Edema in the lower extremities:
Incorrect: Edema in the lower extremities is more characteristic of right-sided heart failure. In left-sided failure, pulmonary congestion is more prominent.
B. Ascites:
Incorrect: Ascites, or fluid accumulation in the abdominal cavity, is also more commonly associated with right-sided heart failure.
C. Shortness of breath:
Correct Answer: Left-sided congestive heart failure can lead to pulmonary congestion, resulting in difficulty breathing or shortness of breath. This is often observed as increased work of breathing, rapid breathing, or other signs of respiratory distress in infants.
D. Hepatomegaly:
Incorrect: Hepatomegaly, or enlargement of the liver, is another manifestation more commonly associated with right-sided heart failure.
Correct Answer is D
Explanation
A. "This shunting allows oxygenated and unoxygenated blood to mix."
Explanation: This statement is correct. In PDA, the shunting of blood between the aorta and pulmonary artery allows oxygenated and unoxygenated blood to mix, leading to decreased oxygen saturation in the systemic circulation.
B. "Blood is shunted to the right side of the heart."
Explanation: This statement is correct. In PDA, blood is shunted from the left side of the heart (aorta) to the right side of the heart (pulmonary artery).
C. "This shunting results in increased pulmonary blood flow."
Explanation: This statement is correct. PDA leads to increased pulmonary blood flow as a result of the shunting of blood from the aorta to the pulmonary artery.
D. "Blood is shunted to the left side of the heart."
Explanation:
A patent ductus arteriosus (PDA) is a congenital heart defect where the ductus arteriosus, a fetal blood vessel that normally closes shortly after birth, remains open. In PDA, blood is shunted from the aorta (left side of the heart) to the pulmonary artery (right side of the heart), resulting in increased pulmonary blood flow. Therefore, the correct statement is that "Blood is shunted to the right side of the heart."
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