A nurse is obtaining a health history from a child who has suspected acute rheumatic fever. Which of the following questions should the nurse ask?

"Has your child had any injuries recently?"

"Has your son had a sore throat recently?"

"Was your son born with this cardiac defect?"

"Have you given your child aspirin in the past 2 weeks?"

Answer and Explanation

The Correct Answer is B

A. Injuries are unrelated to rheumatic fever.

B. A recent streptococcal throat infection is the primary risk factor for acute rheumatic fever. The disease is an inflammatory response to untreated or inadequately treated group A streptococcal (GAS) pharyngitis.

C. Rheumatic fever is not congenital; it is an acquired condition.

D. Aspirin use is more relevant to Reye’s syndrome, not rheumatic fever.

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Correct Answer is D

Explanation

A. The influenza vaccine is not routinely given before 6 months of age.

B. DTaP is not contraindicated and should be given on schedule.

C. Withholding vaccines unnecessarily delays protection.

D. The presence of a mild illness or exposure to illness (such as flu) is not a contraindication to routine vaccinations. The infant should receive all scheduled vaccines.

A. Bradypnea B. Hypertension C. Flushing of the skin D. Oliguria

Correct Answer is D

Explanation

A. Bradypnea – Clients in shock typically exhibit tachypnea (rapid breathing) as the body attempts to compensate.

B. Hypertension – Hypovolemic shock causes hypotension due to reduced blood volume.

C. Flushing of the skin – Clients in shock often have pale, cool, and clammy skin due to vasoconstriction.

D. Oliguria – Hypovolemic shock reduces blood flow to the kidneys, leading to decreased urine output (<30 mL/hr in adults, <1 mL/kg/hr in children).

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A nurse is obtaining a health history from a child who has suspected acute rheumatic fever. Which of the following questions should the nurse ask?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A mother brings her 4-month-old infant in for a routine checkup and vaccinations. The mother reports that the infant was exposed to a brother who has the flu. Which action by the nurse is most appropriate based on these assessment findings?

Correct Answer is D

Explanation

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Correct Answer is D

Explanation

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