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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["120"]
Explanation
Calculate the total drops per hour:
Formula:
Total drops/hour = Volume (mL/hr) x Drop factor (gtt/mL)
=120 mL/hr x 60 gtt/mL
= 7200 gtt/hr
Calculate the drops per minute:
Formula:
Drops per minute (gtt/min) = Total drops/hour / 60 minutes/hour
=7200 gtt/hr / 60 min/hr
= 120 gtt/min
The nurse should set the IV flow rate to deliver 120 gtt/min.
Correct Answer is B
Explanation
A. An electrical source. Electrical burns often cause deep tissue damage that may not be visible on the surface. These burns can extend beyond the skin, affecting muscles, nerves, and internal organs, making them more severe than partial-thickness burns.
B. Contact with hot liquid. Scald burns from hot liquids (e.g., boiling water, coffee, soup) are a common cause of partial-thickness burns. These burns affect the epidermis and part of the dermis, leading to blistering, redness, and pain.
C. A mild sunburn. Mild sunburns typically cause superficial burns (first-degree burns), affecting only the epidermis and resulting in redness and discomfort without blisters. Partial-thickness burns involve deeper skin layers.
D. Contact with a flame. Direct contact with a flame is more likely to cause deeper burns, often resulting in full-thickness burns (third-degree) rather than partial-thickness burns.
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