A preschool-aged child who is being tested for Streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding
provides the clearest indication to the nurse that the child is experiencing a reaction to toxins that are created by Streptococcal bacteria?
Flushed, peeling skin
Red bumps across chest
White coating on tongue
High, protracted fever
The Correct Answer is B
Choice A reason: Flushed, peeling skin is not a specific finding for scarlet fever. Flushed, peeling skin can be caused by various factors, such as sunburn, dehydration, allergic reaction, or infection. Scarlet fever is a condition that results from a Streptococcal infection in the throat or skin that produces toxins that cause a rash and fever. The rash usually begins on the neck and chest and then spreads to other parts of the body.
Choice B reason: This is the correct answer because red bumps across chest are a characteristic finding for scarlet fever. Red bumps across chest are part of the rash that develops due to toxins produced by Streptococcal bacteria. The rash usually feels like sandpaper and may be accompanied by itching or burning sensations. The rash typically lasts for about a week and then fades, leaving behind peeling skin.
Choice C reason: White coating on tongue is not a clear indication for scarlet fever. White coating on tongue can be caused by various factors, such as dehydration, poor oral hygiene, fungal infection, or inflammation. Scarlet fever may cause white patches or red spots on the tongue, but this is not a distinctive feature of scarlet fever.
Choice D reason: High, protracted fever is not a unique finding for scarlet fever. High, protracted fever can be caused by various factors, such as infection, inflammation, dehydration, or immunological disorder. Scarlet fever may cause high fever (above 101°F or 38.3°C), but this is not a definitive sign of scarlet fever.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Determining the need for urinary catheterization is not a task that the nurse should assign to the PN, as this requires clinical judgment and critical thinking, which are beyond the scope of practice of the PN. This is a distractor choice.
Choice B reason: Titrating oxygen to prescribed parameters is a task that the nurse can assign to the PN, as this involves following orders and protocols, which are within the scope of practice of the PN. Therefore, this is the correct choice.
Choice C reason: Receiving a postoperative client and conducting the assessment is not a task that the nurse should assign to the PN, as this requires initial assessment and data collection, which are the responsibility of the registered nurse. This is another distractor choice.
Choice D reason: Evaluating and updating plans of care for clients is not a task that the nurse should assign to the PN, as this requires nursing diagnosis and outcome identification, which are part of the nursing process that only the registered nurse can perform. This is another distractor choice.
Correct Answer is C
Explanation
Choice A reason: Notifying the healthcare provider is an important action, but not the first one. The nurse should prioritize interventions that address the client's immediate needs, such as oxygenation and circulation.
Choice B reason: Preparing a continuous heparin infusion per protocol is an appropriate action for preventing further clot formation and reducing the risk of recurrent pulmonary embolism, but it is not the first action. The nurse should first stabilize the client's condition before administering anticoagulant therapy.
Choice C reason: This is the correct answer because providing supplemental oxygen is the first action that the nurse should take to improve the client's oxygenation and reduce hypoxia. Pulmonary embolism can cause impaired gas exchange and respiratory distress, which can lead to cardiac arrest and death if not treated promptly.
Choice D reason: Bringing the emergency crash cart to the bedside is a prudent action, but not the first one. The nurse should prepare for possible cardiopulmonary resuscitation (CPR) in case of cardiac arrest, but should first attempt to prevent it by providing oxygen and other supportive measures.
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