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 A
Explanation
The correct answer is: A. Tugging on the affected ear lobe.
Choice A reason:
Tugging on the affected ear lobe is a common sign of discomfort in children with otitis media. This behavior indicates that the child is experiencing pain or pressure in the ear, which is a typical symptom of this condition. Children often cannot verbalize their discomfort, so they may tug or pull at their ears to express their pain.
Choice B reason:
Erythema and edema of the affected ear are more indicative of otitis externa (swimmer's ear) rather than otitis media. Otitis media involves inflammation and infection of the middle ear, which is not typically visible externally. The primary signs of otitis media are observed through otoscopic examination, showing a bulging or erythematous tympanic membrane.
Choice C reason:
Pain when manipulating the affected ear lobe is also more characteristic of otitis externa. In otitis media, the pain is usually deeper within the ear and not exacerbated by touching the outer ear. The pain in otitis media is due to the pressure and inflammation in the middle ear space.
Choice D reason:
Clear drainage from the affected ear is not typical of otitis media. If there is drainage, it is usually purulent (pus-like) and indicates a ruptured eardrum due to the infection. Clear drainage is more commonly associated with conditions like otitis externa or a perforated eardrum without infection.
Correct Answer is D
Explanation
Choice A reason: wrong because applying cool compresses for 20 minutes every hour is not typically recommended.While cool compresses can help reduce joint swelling and pain, they are usually recommended to be applied for short periods and not as frequently as every hour
Choice B reason: wrong because while rest is important, there is no specific recommendation for a 45-minute nap daily.Adequate rest should be balanced with physical activity, which is essential for maintaining joint function and muscle strength
Choice C reason: wrong because allowing the child to stay at home on days when her joints are painful may lead to prolonged inactivity, which can worsen joint stiffness and reduce muscle strength.It’s important to encourage regular movement and activity as tolerated
Choice D reason: This is correct because prednisone is a corticosteroid used to reduce inflammation in conditions like juvenile idiopathic arthritis, and an alternate-day schedule can be effective in managing symptoms while minimizing side effects
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