In developing a plan of care for the child diagnosed with rheumatic fever, the nursing intervention that takes the highest priority for this child is to:
Provide age-appropriate diversional activities.
Auscultate heart sounds.
Monitor the C-reactive protein and ESR levels.
Position the child to relieve joint pain.
The Correct Answer is B
Choice A rationale
Providing diversional activities is important for psychological well-being and managing boredom during prolonged bed rest, which is often prescribed to minimize cardiac workload in acute rheumatic fever. However, this is a comfort and developmental intervention, and it does not address the immediate, life-threatening potential for carditis, which is the most serious complication of the disease process, making other choices higher priority.
Choice B rationale
Rheumatic fever is a delayed, non-suppurative complication of Group A beta-hemolytic Streptococcus infection that can lead to carditis (inflammation of the heart muscle, valves, and pericardium), which is the most critical complication. Frequent auscultation of heart sounds is the highest priority intervention to detect new or worsening murmurs, rubs, or gallops, which are direct signs of cardiac inflammation and potential valve damage. Normal heart rate is 60 to 100 beats per minute.
Choice C rationale
C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are non-specific inflammatory markers that indicate the presence and severity of the disease process, with normal CRP typically <10 mg/L and normal ESR typically <20 mm/hr. Monitoring these labs is vital for tracking the disease activity and response to treatment, but this is a diagnostic/monitoring intervention, not a direct action for a life-threatening complication, making it secondary to cardiac assessment.
Choice D rationale
Polyarthritis is a common, painful, but usually temporary manifestation of rheumatic fever, and positioning the child to relieve joint pain is a critical comfort measure. While essential for pain management and rest, joint pain, unlike carditis, does not carry the risk of permanent organ damage or fatality, thus making this intervention less critical than cardiac assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Shortness of breath, or dyspnea, particularly during physical activity like playing, is a classic sign of heart failure in children. This occurs due to pulmonary congestion and increased pulmonary venous pressure caused by the heart's inability to pump blood efficiently, leading to fluid backup into the lungs and reduced gaseous exchange capacity.
Choice B rationale
Crackles (rales) heard on lung auscultation are indicative of fluid accumulation in the alveoli and small airways, which results from pulmonary edema due to left-sided heart failure. This finding is a direct manifestation of the increased hydrostatic pressure in the pulmonary capillaries, causing transudation of fluid into the lung tissue.
Choice C rationale
Tiring easily when eating, often described as poor feeding or difficulty sucking, is a common symptom of heart failure in infants. This fatigue is due to the increased metabolic demands and energy expenditure required for sucking and the effort associated with early pulmonary congestion and tachypnea.
Choice D rationale
Bradycardia, an abnormally slow heart rate (normal heart rate for a school-age child is 60-100 beats/min), is generally not an expected finding in pediatric heart failure. Tachycardia (fast heart rate) is the body's compensatory mechanism to maintain adequate cardiac output in the presence of poor contractility or high volume load, and it is a typical finding.
Correct Answer is ["A","C"]
Explanation
Choice A rationale
The statement that the child needs to stay in bed for only 4–6 hours post-catheterization indicates the need for further teaching. For a venous approach, bed rest is typically required for 4–6 hours, but for an arterial approach, the standard period is 6–8 hours to allow adequate sealing of the vessel puncture site and minimize the risk of bleeding or hematoma formation. The nurse should confirm the specific approach and stress adherence to the minimum 6–8 hours for arterial entry to ensure vessel integrity is maintained.
Choice B rationale
The statement "I should apply pressure to the site in his groin if it starts to bleed" indicates an appropriate understanding of the required post-catheterization care and does not require further teaching. If bleeding occurs at the puncture site after discharge, the priority is to apply continuous, firm pressure immediately above the site to compress the vessel against the underlying bone, a crucial first-aid measure to control hemorrhage before seeking emergency medical help.
Choice C rationale
The statement that "A fever after the procedure is normal for a day or so" is incorrect and requires immediate correction. While a low-grade temperature elevation is possible in the first few hours due to the invasive nature of the procedure, a persistent or high fever is not normal and is often the earliest sign of infection, such as at the site or a systemic infection (sepsis). Parents should be instructed to report any fever (temperature ≥ 38.0°C or 100.4°F) immediately to their healthcare provider.
Choice D rationale
The statement "I can start his medications when we get home" indicates an appropriate understanding, assuming the child's regular medications were held temporarily for the procedure. Unless instructed otherwise by the cardiologist, the routine for most non-procedure-specific medications, such as maintenance drugs for heart failure or chronic conditions, is to resume them as scheduled once the child is stable and home to ensure continued management of their underlying cardiac condition. —.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.