When obtaining a history from the father of a 9-year-old boy with rheumatic fever, the nurse recognizes that the most significant information related to the diagnosis is:
Had an upper respiratory infection with a sore throat about 3 weeks ago.
Suffered chest trauma with a fractured rib after a bicycle accident 2 weeks ago.
The child was born with a heart defect that was repaired at 6 months of age.
Has had a decreasing appetite over the course of several months.
The Correct Answer is A
Choice A reason: This is the correct choice. Rheumatic fever is often preceded by an upper respiratory infection caused by group A Streptococcus, which can lead to a sore throat.
Choice B reason: Chest trauma and a fractured rib are not related to the development of rheumatic fever.
Choice C reason: Although a pre-existing heart defect can increase the risk of complications, it is not the cause of rheumatic fever.
Choice D reason: A decreasing appetite over several months is not specifically indicative of rheumatic fever.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Asking the client to choose the medication is not appropriate as the nurse should use clinical judgment to select the medication based on effectiveness and onset of action.
Choice B reason: Documentation is important but should not precede the administration of pain relief.
Choice C reason: Comparing the pain scale rating with prescribed dosing is part of pain management, but the immediate concern is to relieve the pain as quickly as possible.
Choice D reason: This is the correct choice. The nurse should determine which medication will provide the quickest relief from pain, which is the client's immediate need.
Correct Answer is D
Explanation
Choice A reason: Non-opioid analgesics are typically not strong enough to manage the severe pain associated with a sickle cell crisis.
Choice B reason: Guided imagery can be a helpful adjunct, but it is not the primary method of pain control during a crisis.
Choice C reason: Diversional activities may help distract from the pain but are not sufficient as the sole method of pain management.
Choice D reason: This is the correct choice. An IV PCA (patient-controlled analgesia) allows the child to manage pain effectively and is appropriate for severe pain during a sickle cell crisis.
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