The parents of a 7-year-old child bring her to the emergency department. They tell the nurse that she awoke with a tympanic temperature of 39.2 (102.2°), an extremely sore throat, drooling, and difficulty swallowing. Which of the following actions is the nurse's priority?

Obtain culture specimens.

Administer an antipyretic.

Prepare for intubation.

Insert an IV catheter.

Answer and Explanation

The Correct Answer is C

A. While obtaining culture specimens is important, the priority in this case is managing the child’s airway, as drooling and difficulty swallowing suggest potential airway obstruction.

B. Administering an antipyretic is not the priority; airway management is more urgent in this situation.

C. The priority is to prepare for intubation, as the child’s symptoms suggest possible epiglottitis, which can cause rapid airway obstruction. Securing the airway is critical.

D. Inserting an IV catheter is important for hydration and medication administration, but airway management is the immediate priority.

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Correct Answer is B

Explanation

A. Unintelligible speech is common at 18 months and typically resolves with age. However, a hearing screening may still be appropriate to rule out any issues.

B. By 6 months of age, infants should begin making babbling sounds. The absence of babbling at 8 months suggests a potential hearing impairment and warrants further evaluation.

C. Preferring to play with others is typical behavior for a 4-year-old and does not indicate a hearing impairment.

D. An exaggerated startle response at 3 months is a normal developmental milestone and does not indicate a hearing problem.

A. Auscultating the rate and characteristics of the child's heart sounds B. Using a pain-rating tool to determine the severity of the joint pain C. Assessing the client's erythematous rash D. Identifying the degree of parental anxiety related to the diagnosis

Correct Answer is A

Explanation

A. Acute rheumatic fever can cause carditis, which may lead to heart murmurs, tachycardia, or heart failure. Assessing heart sounds is a priority to identify potential complications.

B. Joint pain is an important concern in acute rheumatic fever, but the immediate priority is assessing for signs of carditis or heart complications.

C. An erythematous rash is a characteristic of acute rheumatic fever but is less critical to address immediately compared to potential cardiac involvement.

D. Parental anxiety should be addressed, but the priority is assessing the child’s physical condition, particularly the heart.

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The parents of a 7-year-old child bring her to the emergency department. They tell the nurse that she awoke with a tympanic temperature of 39.2 (102.2°), an extremely sore throat, drooling, and difficulty swallowing. Which of the following actions is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing Evaluation?

Correct Answer is B

Explanation

A nurse is caring for an 8-year-old child who has acute rheumatic fever. Which of the following assessments is the nurse's priority immediately after admission?

Correct Answer is A

Explanation

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