Question

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?

Answer 1

Correct Answers:

Auscultating the rate and characteristics of the child's heart sounds

Rationale :

💁‍♂️Auscultating heart sounds is the priority because acute rheumatic fever commonly leads to carditis, which can affect the function of heart valves and result in serious complications.

🩺Cardiac involvement is the most life-threatening manifestation of rheumatic fever and requires prompt identification to initiate appropriate interventions.

⚠️Heart murmurs or changes in heart sounds may indicate valvular damage, such as mitral regurgitation, which can progress if undetected.

📉Prioritizing cardiovascular assessment aligns with the ABC (Airway, Breathing, Circulation) framework used in identifying critical concerns.

📌Core Message

Cardiac assessment is the priority in rheumatic fever due to the risk of carditis and valvular damage.

Answer 2

Correct Answers:

Shake the inhaler for 3 to 5 seconds.

Rationale :

🔄Shaking the inhaler for 3 to 5 seconds ensures the medication is properly mixed before administration, which is essential for consistent and effective dosing.

💨An MDI contains both medication and propellant, which can separate during storage; shaking redistributes them evenly.

👃Proper administration technique enhances absorption in the lungs and improves therapeutic outcomes.

📚Teaching accurate use techniques promotes medication adherence and reduces complications in chronic respiratory conditions like asthma.

📌Core Message

Ensure MDI medication is mixed properly by shaking before use to maximize effectiveness.

Answer 3

Correct Answers:

83

Rationale :

💁‍♂️To calculate: 1000 mL ÷ 12 hr = 83.33 mL/hr, rounded to the nearest whole number = 83 mL/hr.

⏱️IV infusion calculations are critical to prevent under- or over-infusion, which could lead to fluid imbalance or complications.

💧This formula helps regulate safe fluid administration over a specified period.

📏Rounding correctly ensures pump accuracy while aligning with standard nursing practice.

📌Core Message

Use volume ÷ time to calculate safe IV infusion rates, then round correctly.

Answer 4

Correct Answers:

A sibling who had a sore throat 3 weeks ago

Rationale :

🦠A recent streptococcal throat infection is the most likely precursor to acute rheumatic fever, a post-infectious inflammatory condition.

👨‍👩‍👧Close contact with a sibling who had a sore throat increases the risk of Group A beta-hemolytic streptococcus transmission.

📆The timeline of 2 to 3 weeks post-infection is consistent with the incubation period for rheumatic fever development.

🏥Identifying the source of infection is crucial for both treatment and education to prevent recurrence in household contacts.

📌Core Message

Rheumatic fever often follows an untreated strep throat, especially within the family unit.

Answer 5

Correct Answers:

"We will sit the child upright and forward and apply pressure to the sides of the nose."

Rationale :

🩸Leaning forward while pinching the nasal bridge helps prevent blood aspiration and facilitates clotting.

👃Applying pressure to the soft part of the nose compresses the bleeding vessels, commonly in Kiesselbach’s plexus.

🚫Incorrect positions like lying flat or tilting the head back can lead to blood pooling in the throat, increasing the risk of aspiration or vomiting.

📖Proper first-aid education is essential in preventing recurrent episodes and teaching effective home care.

📌Core Message

For epistaxis, use an upright, forward-leaning position with pressure on the nasal bridge.

Answer 6

Correct Answers:

Encourage the parents to rock the infant.

Rationale :

🤱Soothing activities like rocking can provide comfort and reduce agitation without risking surgical site disruption.

🚫Positioning the infant on the abdomen post-cleft lip repair is contraindicated due to the risk of trauma to the suture line.

🧴Pacifiers should be avoided to prevent stress on the surgical area and potential wound dehiscence.

💊Ibuprofen is not recommended in infants under 6 months due to safety concerns; acetaminophen is the preferred analgesic.

📌Core Message

Post-op care for cleft lip includes comforting techniques that do not disrupt the suture line.

Answer 7

Correct Answers:

Position the child side-lying.

Rationale :

🤢The side-lying position protects the airway during a seizure, especially if the child is vomiting.

🛡️This position allows for drainage of secretions and reduces the risk of aspiration, which can lead to pneumonia.

⚡During seizures, maintaining a patent airway is the top priority, following the ABC approach.

🧠Other interventions like loosening clothing or cushioning the head are supportive but come after ensuring the airway is protected.

📌Core Message

In seizures with vomiting, side-lying position is key for airway protection and aspiration prevention.

Answer 8

Correct Answers:

"Test the urine for ketones."

Rationale :

🧪During illness, children with type 1 diabetes are at risk for diabetic ketoacidosis (DKA), even if their blood glucose is not critically elevated.

⚠️Ketone testing helps identify early signs of metabolic decompensation and guides adjustments in insulin therapy.

🥤Sick-day guidelines emphasize maintaining hydration, continuing insulin, and frequent glucose and ketone monitoring.

📚This teaching is vital to prevent life-threatening complications during intercurrent illnesses.

📌Core Message

During illness, children with type 1 diabetes must monitor ketones to prevent DKA.

Answer 9

Correct Answers:

Tachycardia

Rationale :

❤️Tachycardia is a common symptom of hypoglycemia, resulting from sympathetic nervous system activation as the body responds to low glucose.

🧠Neurogenic symptoms like shakiness and difficulty speaking are also typical due to glucose deficiency in the brain.

📉A glucose level of 55 mg/dL is below the normal range and necessitates prompt intervention to prevent loss of consciousness.

🚑Recognizing and responding to early signs prevents severe neurologic complications.

📌Core Message

Tachycardia is a key sign of hypoglycemia due to sympathetic stimulation.

Answer 10

Correct Answers:

"Toddlers are beginning to develop a desire for autonomy. Temper tantrums are normal during this stage."

Rationale :

🧠Autonomy vs. shame and doubt is the developmental stage for toddlers, as described by Erikson, and often includes testing boundaries.

😡Temper tantrums reflect normal emotional expression during this stage as toddlers learn to assert independence.

👶Parental education is important to reassure caregivers and reduce frustration by setting appropriate expectations.

📚Understanding this behavior as developmentally appropriate prevents unnecessary concern or harsh discipline.

📌Core Message

Temper tantrums are a normal expression of autonomy in toddler development.

1 :
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?

2 :
A nurse is providing discharge teaching to a client has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching?

3 :
A nurse is preparing to administer 5% dextrose in 0.45% sodium chloride 1,000 mL IV to infuse over 12 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

4 :
A nurse is caring for a child who has rheumatic fever. When obtaining the child's medical history from the parent, the nurse should recognize the significance of which of the following data as the possible source of the child's infection?

5 :
A nurse is teaching the parents of a child with frequent nosebleeds how to care for the child. Which statement by the parents indicate that the parents have understood the teaching?

6 :
A nurse is caring for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?

7 :
A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

8 :
A nurse is teaching a school-age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following instructions should the nurse include?

10 :
A nurse is assessing a 2-year-old child at a well-child visit. The child's parent expresses concern about the child's increasing temper tantrums and difficult behaviors. Which of the following statements should the nurse respond with?

1 : 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?

2 : A nurse is providing discharge teaching to a client has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching?

3 : A nurse is preparing to administer 5% dextrose in 0.45% sodium chloride 1,000 mL IV to infuse over 12 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

4 : A nurse is caring for a child who has rheumatic fever. When obtaining the child's medical history from the parent, the nurse should recognize the significance of which of the following data as the possible source of the child's infection?

5 : A nurse is teaching the parents of a child with frequent nosebleeds how to care for the child. Which statement by the parents indicate that the parents have understood the teaching?

6 : A nurse is caring for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?

7 : A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

8 : A nurse is teaching a school-age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following instructions should the nurse include?

10 : A nurse is assessing a 2-year-old child at a well-child visit. The child's parent expresses concern about the child's increasing temper tantrums and difficult behaviors. Which of the following statements should the nurse respond with?

1 :
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?

2 :
A nurse is providing discharge teaching to a client has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching?

3 :
A nurse is preparing to administer 5% dextrose in 0.45% sodium chloride 1,000 mL IV to infuse over 12 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

4 :
A nurse is caring for a child who has rheumatic fever. When obtaining the child's medical history from the parent, the nurse should recognize the significance of which of the following data as the possible source of the child's infection?

5 :
A nurse is teaching the parents of a child with frequent nosebleeds how to care for the child. Which statement by the parents indicate that the parents have understood the teaching?

6 :
A nurse is caring for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?

7 :
A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

8 :
A nurse is teaching a school-age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following instructions should the nurse include?

10 :
A nurse is assessing a 2-year-old child at a well-child visit. The child's parent expresses concern about the child's increasing temper tantrums and difficult behaviors. Which of the following statements should the nurse respond with?