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A 7-year-old child has been admitted to the hospital with a diagnosis of acute rheumatic fever. When taking a health history from the child's mother, which recent illness is of most significance?
- A. Chickenpox.
- B. Mumps.
- C. Sore throat.
- D. Influenza.
Correct Answer: C
Rationale: A recent untreated strep throat can lead to acute rheumatic fever.
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The nurse is evaluating a child with acute glomerulonephritis who presents at the clinic with increased fatigue, facial swelling, and decreased appetite. The child's urine sample is dark yellow. What additional finding should the nurse report to the healthcare provider?
- A. Blood pressure 88/50 mmHg
- B. Weight loss
- C. Maculopapular rash over the trunk of the body
- D. Positive rapid strep test of the oropharynx
Correct Answer: D
Rationale: A positive strep test indicates a recent infection, a common cause of glomerulonephritis, requiring reporting.
The parents of a newborn with hypospadias are anxious about the timing of the surgical correction. What information should the nurse share with them?
- A. Surgery should be performed within one month to prevent bladder infections.
- B. Postponing the repair until the child reaches school age can alleviate fears of castration.
- C. The repair should be completed before the child is toilet-trained.
- D. The urethral repair should be carried out after the child reaches sexual maturity.
Correct Answer: C
Rationale: Repair before toilet training supports normal urinary function and reduces psychological impact.
While checking the vital signs of a 10-year-old child who underwent a tonsillectomy earlier in the day, the nurse notices the child swallowing every 2 to 3 minutes. What action should the nurse take next?
- A. Check for signs of teeth clenching or grinding
- B. Inspect the back of the throat
- C. Stimulate the gag reflex by touching the tonsillar pillars
- D. Ask the child to speak to assess for any changes in voice tone .
Correct Answer: B
Rationale: Frequent swallowing may indicate post-tonsillectomy bleeding, requiring throat inspection.
The nurse is caring for an adolescent with scoliosis who is recovering after a surgical spinal instrumentation. Which technique should the nurse use when moving the client?
- A. Flex the knees.
- B. Raise the hips.
- C. Cross the arms and legs.
- D. Perform a log roll.
Correct Answer: D
Rationale: Log rolling maintains spinal alignment, protecting the surgical site during movement.
The nurse is providing education to parents about preventing otitis media recurrence in their infant. Which instruction should the nurse include?
- A. Position prone after feeding.
- B. Breastfeed frequently.
- C. Avoid smoke exposure.
- D. Inspect the infant's ears daily.
Correct Answer: C
Rationale: Avoiding smoke exposure reduces eustachian tube irritation, lowering otitis media risk.