The nurse is assessing a child admitted with a diagnosis of rheumatic fever. Which significant question would the nurse ask the child's parent during the assessment?

"Has your child been exposed to anyone with chicken pox

"Has any family member had a sore throat within the past few weeks?"

"Has any family member had a gastrointestinal disorder in the past few weeks?

"Has your child had difficulty urinating?

Answer and Explanation

The Correct Answer is B

A. "Has your child been exposed to anyone with chicken pox?"
While chickenpox is caused by a different virus (varicella-zoster virus) and is not directly linked to rheumatic fever, the nurse might inquire about exposure to contagious illnesses as a general part of the assessment.
B. "Has any family member had a sore throat within the past few weeks?"
This question is relevant because rheumatic fever often follows an untreated or inadequately treated group A streptococcal infection, such as strep throat. A sore throat in a family member could indicate the presence of streptococcal infection, which is a crucial factor in the development of rheumatic fever.
C. "Has any family member had a gastrointestinal disorder in the past few weeks?"
Gastrointestinal disorders are not directly associated with the development of rheumatic fever. However, a comprehensive medical history might include questions about recent illnesses to understand the overall health context.
D. "Has your child had difficulty urinating?"
Difficulty urinating is not a typical symptom or risk factor associated with rheumatic fever. This symptom would likely prompt investigation into other potential issues but is not specifically related to rheumatic fever.

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Correct Answer is C

Explanation

A. 9 months: By 9 months, most infants would have well exceeded doubling their birth weight.
B. 12 months: Doubling of birth weight usually occurs earlier, by around 5 to 6 months, rather than 12 months.
C. 6 months
Explanation:
The general guideline is that infants tend to double their birth weight by around 5 to 6 months of age. This doubling of birth weight is a common marker of healthy growth and development during the first few months of life.
D. 3 months: By 3 months, while infants experience significant growth, they usually haven't doubled their birth weight yet.

A. "I am unable to discuss this, but I can contact my supervisor to speak with you." B. "As a nurse. I am required by law to report suspected child abuse." C. I reported the incident to my supervisor who decided to contact the authorities." D. "The provider will be coming to explain the situation.

Correct Answer is B

Explanation

A. "I am unable to discuss this, but I can contact my supervisor to speak with you."
Explanation: While it is appropriate to involve a supervisor in difficult situations, the nurse should first clarify the legal obligation to report suspected child abuse. This response may leave the impression that the nurse is avoiding the question.
B. "As a nurse, I am required by law to report suspected child abuse."
Explanation:
Nurses are mandated reporters, meaning they are legally obligated to report suspected child abuse. It is important to communicate this legal obligation to the parents when they inquire about the reason for the report. This response is honest, direct, and reinforces the nurse's ethical and legal responsibility to prioritize the well-being and safety of the child.
C. "I reported the incident to my supervisor who decided to contact the authorities."
Explanation: This response may create confusion about the reporting process. It is important to convey that reporting is a legal obligation for the nurse, and it is not solely at the discretion of the supervisor.
D. "The provider will be coming to explain the situation."
Explanation: While involving other healthcare professionals, such as a provider, may be part of the process, it is crucial to emphasize the nurse's legal responsibility to report suspected child abuse. This response does not clearly communicate the legal obligation that the nurse has in reporting such incidents.

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The nurse is assessing a child admitted with a diagnosis of rheumatic fever. Which significant question would the nurse ask the child's parent during the assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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