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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A: Lice cannot survive for more than 48 hours away from the host. This statement is false and should not be included in the teaching, as it can cause unnecessary anxiety or confusion.

Choice B: Washing your child's hair daily will not prevent lice, as lice do not depend on hair cleanliness or hygiene. This statement is false and should not be included in the teaching, as it can create a false sense of security or stigma.

Choice C: Lice cannot jump or ﬂy from one child to another, as they only crawl. This statement is false and should not be included in the teaching, as it can cause unnecessary fear or panic.

Choice D: Encouraging your child to avoid sharing hats with other children can prevent lice, as lice can be transmitted by direct contact or by sharing personal items. This statement is true and should be included in the teaching, as it can help prevent lice infestation or spread.

Correct Answer is ["260"]

Explanation

Sure, let’s calculate the total fluid intake step by step.

Step 1: Convert ½ cup of juice to mL.

1 cup = 240 mL
½ cup = 240 mL ÷ 2 = 120 mL
Result: 120 mL

Step 2: Convert 3 oz of gelatin to mL.

1 oz = 30 mL
3 oz = 3 × 30 mL = 90 mL
Result: 90 mL

Step 3: Convert 1 oz of an ice pop to mL.

1 oz = 30 mL
1 oz = 30 mL
Result: 30 mL

Step 4: Ginger ale is already in mL.

Result: 20 mL

Step 5: Add all the mL values together.

120 mL (juice) + 90 mL (gelatin) + 30 mL (ice pop) + 20 mL (ginger ale) = 260 mL
Result: 260 mL

The nurse should record the child’s fluid intake as 260 mL.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching about lice to the parents of a school-age child at a well-child visit. Which of the the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed ½ cup of juice, 3 oz gelatin, 1 oz of an ice pop, and 20 mL of ginger ale. How many mL should the nurse record as the child's ﬂuid intake?

Correct Answer is ["260"]

Explanation

A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture to rule out meningitis. Which of the following actions should the nurse include in the plan of care?

A nurse is performing a pre-college physical assessment on an adolescent. Which of the following immunizations should the nurse anticipate administering?

A nurse is providing teaching about self-administration of insulin to the parent of a school-age child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent indicates a need for further teaching?

A nurse is reviewing data for four children. Which of the following children should the nurse assess first?

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane? (The child will likely view this as invasive and traumatic)

A nurse is assessing a school-age child whose blood glucose level is 280 mg/dL. Which of the following findings should the nurse expect?

A nurse is providing discharge teaching to the parents of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parents indicates an understanding of the teaching?

A nurse is caring for a child who has pertussis. The child's parent asks the nurse what the common name for this disease is. The nurse should respond with which of the following common names?