A nurse is collecting data from the chart of a child who has streptococcal pharyngitis after being admitted for suspected rheumatic fever. Which of the following findings should the nurse identify as an indication of possible rheumatic fever? (Select All that Apply)

Atrial fibrillation on the cardiac monitor

Elevated BUN and creatinine on morning laboratory results

Involuntary movements of extremities

Alopecia

Report of chest pain

Oliguria

Answer and Explanation

Correct Answer : C,E

A. Atrial fibrillation on the cardiac monitor. Rheumatic fever can cause carditis, but atrial fibrillation is not a typical finding. Instead, valvular damage, tachycardia, or murmurs are more commonly observed.

B. Elevated BUN and creatinine on morning laboratory results. Rheumatic fever primarily affects the heart, joints, skin, and brain, not the kidneys. Elevated BUN and creatinine are more indicative of post-streptococcal glomerulonephritis, a separate complication of streptococcal infection.

C. Involuntary movements of extremities. Sydenham’s chorea, characterized by involuntary, jerky movements, is a classic neurologic manifestation of rheumatic fever. It results from inflammation affecting the basal ganglia of the brain.

D. Alopecia. Rheumatic fever does not cause alopecia. Hair loss is more commonly associated with autoimmune diseases such as lupus, not post-streptococcal complications.

E. Report of chest pain. Chest pain can indicate carditis, a major criterion for rheumatic fever. Inflammation of the heart's endocardium, myocardium, or pericardium may lead to pain, murmurs, or heart failure symptoms.

F. Oliguria. Decreased urine output is more commonly seen in post-streptococcal glomerulonephritis rather than rheumatic fever, as rheumatic fever primarily affects the heart, joints, and nervous system.

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Correct Answer is A

Explanation

A. A 3-year-old toddler who aspirated several sunflower seeds and continues to cough with an O₂ saturation of 91%. This child is the highest priority due to the risk of airway obstruction. Persistent coughing and decreased oxygen saturation suggest partial obstruction, which could worsen. Immediate assessment and intervention are necessary to prevent respiratory distress or complete airway blockage.

B. A 6-year-old child admitted with asthma exacerbation who used a rescue inhaler 16 hours ago. While asthma exacerbations can be serious, this child is currently stable since there is no indication of respiratory distress or worsening symptoms requiring immediate intervention.

C. A 15-year-old adolescent who had a laparoscopic appendectomy 30 hours ago, rates their pain a 3 on a scale of 1 to 10, and is preparing for discharge this morning. This client is stable, with mild pain and no reported complications. They do not require immediate attention.

D. An 18-month-old admitted for dehydration 2 days ago who has had six wet diapers in the last 24 hours and ate 90% of their meals. This child's hydration status appears to be improving, with adequate urine output and good oral intake, making them a lower priority compared to a child with respiratory compromise.

A. "Kawasaki disease is an abnormal immune response that only affects the liver." B. "Kawasaki disease is an abnormal immune response that causes injury to the body's muscles." C. "Kawasaki disease is an abnormal immune response in which the body attacks the skin only." D. "Kawasaki disease is an abnormal immune system response that can weaken the coronary arteries."

Correct Answer is D

Explanation

A. "Kawasaki disease is an abnormal immune response that only affects the liver." This is incorrect. Kawasaki disease primarily affects the blood vessels, especially the coronary arteries, not just the liver. While liver inflammation can occur, it is not the main concern.

B. "Kawasaki disease is an abnormal immune response that causes injury to the body's muscles." This is incorrect. Kawasaki disease is a vasculitis (inflammation of blood vessels), not a muscle disorder. It mainly affects the heart and blood vessels, potentially leading to aneurysms and long-term cardiac complications.

C. "Kawasaki disease is an abnormal immune response in which the body attacks the skin only." This is incorrect. While skin changes (such as a rash, peeling skin, and red palms/soles) are common symptoms, the primary concern is inflammation of the coronary arteries, which can lead to serious heart complications.

D. "Kawasaki disease is an abnormal immune system response that can weaken the coronary arteries." This is correct. Kawasaki disease triggers inflammation in medium-sized arteries, particularly the coronary arteries, which supply blood to the heart. If untreated, this can lead to coronary artery aneurysms, myocardial infarction, or long-term heart disease.

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A nurse is collecting data from the chart of a child who has streptococcal pharyngitis after being admitted for suspected rheumatic fever. Which of the following findings should the nurse identify as an indication of possible rheumatic fever? (Select All that Apply)

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