A nurse is caring for an 8-year-old client who has been diagnosed with acute rheumatic fever. Which action is the nurse's priority for a client with this presentation?
Reviewing the client's complete blood count (CBC).
Using a pain-rating tool to determine the severity of the joint pain.
Assessing the client's erythematous rash.
Auscultating the rate and characteristics of the child's heart sounds.
The Correct Answer is D
A. While reviewing the CBC is important, it is not the priority.
B. Assessing joint pain is necessary for managing symptoms, but it is not the most critical initial action.
C. Evaluating the erythematous rash is part of the assessment, but it does not take precedence.
D. Auscultating the heart is the priority because acute rheumatic fever can lead to carditis, which can cause significant and potentially life-threatening heart complications. Early detection of abnormal heart sounds is crucial.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Neurologic function is not typically affected by nephrotic syndrome, so improvement in this area is not an indicator of recovery.
B. Weight gain might indicate fluid retention rather than recovery in nephrotic syndrome.
C. The absence of protein in the urine indicates that the kidneys are functioning properly and that the syndrome is resolving. Proteinuria is a hallmark of nephrotic syndrome, so its resolution is a key sign of recovery.
D. A negative gram stain is more relevant to infections, not nephrotic syndrome.
Correct Answer is A
Explanation
A. Hemophilia is a bleeding disorder that affects the clotting process, and the partial thromboplastin time (PTT) is typically prolonged in individuals with hemophilia, indicating a deficiency in clotting factors.
B. Hemoglobin levels may remain normal unless the client experiences significant bleeding episodes.
C. Platelet count is usually normal in hemophilia, as the disorder affects clotting factors rather than platelet production.
D. Hematocrit levels may also remain normal unless there is significant bleeding, which would lower hematocrit due to blood loss.
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