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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: It is crucial to assess for fever, as a fever over 100°F after exposure to the flu may indicate an active infection, necessitating the postponement of immunizations.

Choice B reason: Administering vaccinations without assessing the child's health status, especially after known exposure to the flu, could be risky.

Choice C reason: Giving only the flu vaccination ignores the potential risk of the infant currently incubating the flu virus, which could be exacerbated by vaccination.

Choice D reason: While withholding all vaccinations is a cautious approach, it is not necessary unless the infant shows signs of illness, such as a fever over 100°F.

A. Lift and clear drainage from the chest tube. B. Inspect the tube insertion site for leaking. C. Continue to monitor the drainage system. D. Auscultate lungs for unequal breath sounds.

Correct Answer is C

Explanation

Choice A reason: Lifting and clearing drainage from the chest tube is not necessary unless there is a blockage, which is not indicated by the water level changes.
Choice B reason: Inspecting the tube insertion site for leaking is important but not related to the observation of water level changes in the water-seal chamber.
Choice C reason: This is the correct choice. The water level rising during inspiration and falling during expiration is a normal finding that indicates the chest tube is functioning properly.
Choice D reason: Auscultating lungs for unequal breath sounds is part of the assessment but does not address the observed water level changes in the water-seal chamber.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is C

Explanation

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