A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant?
Chickenpox.
Mumps.
Sore throat.
Influenza.
The Correct Answer is C
A. Chickenpox is caused by the varicella-zoster virus and is not directly related to the development of acute rheumatic fever.
B. Mumps is caused by the mumps virus and is not directly related to the development of acute rheumatic fever.
C. Sore throat.
Acute rheumatic fever (ARF) is an inflammatory condition that can occur after an untreated or inadequately treated streptococcal throat infection, such as streptococcal pharyngitis (strep throat). It is caused by group A Streptococcus bacteria.
In ARF, the body's immune response to the streptococcal infection can lead to inflammation and damage to various parts of the body, including the heart, joints, skin, and central nervous system. One of the major criteria for diagnosing ARF is a history of a sore throat. Therefore, the most significant recent occurrence for the health history in this case would be a sore throat (option C).
D. Influenza is caused by the influenza virus and is not directly related to the development of acute rheumatic fever.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Evaluating the infant for failure to thrive (FTT) is not the most appropriate initial intervention in this case. FTT is a long-term growth issue, and the immediate concern is the infant's current symptoms and cardiac status.
B. Auscultate heart and lungs while the infant is held.
Tetralogy of Fallot (TOF) is a congenital heart defect that includes four specific cardiac abnormalities, and it often requires surgical correction in infancy. When an infant with a history of TOF surgery presents with symptoms such as rapid breathing, feeding difficulties, and fatigue, it may raise concerns about potential cardiac issues or complications.
The most appropriate initial intervention is to auscultate the infant's heart and lungs while the infant is held to assess for any abnormal heart sounds or signs of respiratory distress. Auscultation can provide important information about the infant's cardiac and respiratory status. This assessment will help determine if there are any immediate concerns related to the infant's cardiac condition.
C. Stimulating the infant to cry to produce cyanosis is not a recommended or appropriate intervention. Cyanosis is a sign of inadequate oxygenation and should not be induced in a child.
D. Obtaining a 12-lead electrocardiogram may be indicated if there are significant concerns about the infant's cardiac status, but auscultation should be performed first to assess the immediate condition. An electrocardiogram is a diagnostic tool and would be ordered as a follow-up assessment if needed.
Correct Answer is ["B","F","G","H"]
Explanation
A. An electrocardiogram with a tall T wave and widened QRS complex may indicate electrolyte imbalances or cardiac issues, which are not indicative of stabilization.
C. Basilar crackles can be a sign of pulmonary or cardiac issues and are not indicative of stabilization.
D. A urine output of 20 mL in the last hour may suggest reduced kidney function or hydration status and is not indicative of stabilization.
E. A respiratory rate of 26 breaths/minute may indicate respiratory distress and is not indicative of stabilization.
The assessment findings that suggest stabilization include:
A blood pressure within the normal range (126/76 mm Hg).
A heart rate within the normal range (72 beats/minute).
Oxygen saturation of 98% on room air, indicating adequate oxygenation.
A normal body temperature (98.9°F or 37.1°C orally).
These vital signs and clinical parameters are within normal ranges, suggesting that the client's condition is stable at this time.
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