A nurse is caring for an 8-year-old child who has acute rheumatic fever. Which of the following assessments is the nurse's priority immediately after admission?
Using a pain-rating tool to determine the severity of the joint pain
Assessing the client's erythematous rash
Identifying the degree of parental anxiety related to the diagnosis
Auscultating the rate and regularity of the child's heart sounds and notifying the provider immediately of abnormalities
The Correct Answer is D
Choice A: Using a pain-rating tool to determine the severity of the joint pain is not the priority assessment for an 8-year-old child who has acute rheumatic fever, which is an inflammatory condition that can affect various organs, especially the heart, joints, skin, and brain. Joint pain is one of the major criteria for diagnosing acute rheumatic fever and can affect one or more large joints, such as knees, ankles, elbows, or wrists. Joint pain can be managed with analgesics or anti-inflammatory drugs.
Choice B: Assessing the client's erythematous rash is not the priority assessment for an 8-year-old child who has acute rheumatic fever, which is an inflammatory condition that can affect various organs, especially the heart, joints, skin, and brain. The erythematous rash is one of the minor criteria for diagnosing acute rheumatic fever and can appear as pink or red patches on the trunk or limbs. The erythematous rash can fade or change location over time and does not require any specific treatment.
Choice C: Identifying the degree of parental anxiety related to the diagnosis is not the priority assessment for an 8-year-old child who has acute rheumatic fever, which is an inflammatory condition that can affect various organs, especially the heart, joints, skin, and brain. Parental anxiety related to the diagnosis can affect their coping skills and ability to care for their child. Parental anxiety can be addressed by providing education, support, and referral to appropriate resources.
Choice D: Auscultating the rate and regularity of the child's heart sounds and notifying the provider immediately of abnormalities is the priority assessment for an 8-year-old child who has acute rheumatic fever, as it can indicate cardiac involvement, which is the most serious complication of acute rheumatic fever. Cardiac involvement can cause damage to the heart valves, myocardium, or pericardium and lead to heart failure or death. Abnormalities in heart sounds may include murmurs, rubs, gallops, or arrhythmias.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Toys that can't be dry cleaned or washed do not need to be thrown out, as they can be treated by sealing them in plastic bags for two weeks or placing them in a freezer for two days. This will kill any lice or nits that may have been transferred from the child's head.
Choice B: Nits will not always be present, as they can be removed by using a fine-toothed comb or applying products that loosen their attachment to the hair shafts. Nits are the eggs of lice that are glued to the hair near the scalp. Nits can hatch into nymphs within seven to ten days and mature into adult lice within another seven to ten days.
Choice C: All recently used clothing, bedding, and towels must be washed in hot water, as this will kill any lice or nits that may have been transferred from the child's head. Hot water means at least 54°C/130°F for at least ten minutes. The items should also be dried in high heat for at least twenty minutes.
Choice D: Treating all the family members is not necessary, as only those who have evidence of lice or nits should be treated with medicated shampoos or lotions that kill lice and prevent re-infestation. Treating all the family members may cause unnecessary exposure to chemicals or resistance to treatment.
Correct Answer is A
Explanation
Choice A: This response is appropriate, as it informs the parent that reporting suspected child abuse is a legal and ethical obligation for nurses, regardless of their personal opinions or feelings. This response also shows respect and honesty by acknowledging the parent's concern and explaining the reason for the nurse's action.
Choice B: This response is not appropriate, as it deflects responsibility and avoids answering the parent's question. This response also shows disrespect and dishonesty by implying that the provider is more qualified or authorized to explain the situation than the nurse.
Choice C: This response is not appropriate, as it denies information and creates confusion for the parent. This response also shows indifference and avoidance by suggesting that the nurse does not want to deal with the issue or communicate with the parent.
Choice D: This response is not appropriate, as it shifts blame and undermines trust between the nurse and the parent. This response also shows defensiveness and insecurity by implying that the nurse did not make the decision or take accountability for their action.
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