A nurse is caring for a child who has rheumatic fever. When obtaining the child's medical history from the parent, the nurse should recognize the significance of which of the following data as the possible source of the child's infection?

The father who had gastritis 2 weeks ago

A neighbor's child who has chickenpox

A sibling who had a sore throat 3 weeks ago

A classmate who has fifth disease

Answer and Explanation

The Correct Answer is C

A. Gastritis is not an infectious condition and is unlikely to be the source of the child's rheumatic fever.

B. Chickenpox is caused by a different pathogen (varicella-zoster virus) and is not associated with the development of rheumatic fever.

C. Rheumatic fever often follows untreated or inadequately treated streptococcal infections, particularly streptococcal pharyngitis (sore throat). A sibling with a recent sore throat is a significant piece of information.

D. Fifth disease is caused by parvovirus B19 and is not known to be a precursor to rheumatic fever.

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Correct Answer is A

Explanation

A. Tugging or pulling at the ear is a common sign in children with otitis media and may indicate ear pain.

B. Pain when manipulating the affected earlobe is expected in otitis media due to inflammation and infection of the middle ear.

C. Erythema and edema of the affected ear are typical findings in otitis media, indicating inflammation.

D. Clear drainage is not a typical finding in otitis media. Drainage, if present, is more likely to be purulent or serosanguinous.

A. Respiratory rate 20/min B. Blood pressure 92/50 mm Hg C. Heart rate 72/min D. Abdominal pain rated 4 on a scale of 0 to 10

Correct Answer is B

Explanation

A. A respiratory rate of 20/min is within the normal range, and while it should be monitored, it is not the priority in this case.

B. Blood pressure is a critical indicator of perfusion and can be affected by internal bleeding or other serious injuries. A low blood pressure may suggest significant blood loss and is the priority in assessing for shock.

C. A heart rate of 72/min is within the normal range for an adolescent. While it should be monitored, it is not the immediate priority.

D. Abdominal pain is a subjective measure and, while important, may not accurately reflect the severity of internal injuries. The priority is to assess the hemodynamic stability, as indicated by blood pressure.

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A nurse is caring for a child who has rheumatic fever. When obtaining the child's medical history from the parent, the nurse should recognize the significance of which of the following data as the possible source of the child's infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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