Nokea
A child is admitted to the hospital with a diagnosis of rheumatic fever. The nurse reviews the blood laboratory findings, knowing that which finding will confirm the likelihood of this disorder?
- A. Increased leukocyte count
- B. Decreased hemoglobin count
- C. Increased antistreptolysin-O (ASO titer)
- D. Decreased erythrocyte sedimentation rate
Correct Answer: C
Rationale: Children suspected of having rheumatic fever are tested for streptococcal antibodies. The most reliable and best standardized test to confirm the diagnosis is the ASO titer. An elevated level indicates the presence of rheumatic fever. The remaining options are unrelated to diagnosing rheumatic fever. Additionally, an increased leukocyte count indicates the presence of infection but is not specific in confirming a particular diagnosis.
You may also like to solve these questions
The nurse, while caring for a hospitalized infant being monitored for increased intracranial pressure (ICP), notes that the anterior fontanel bulges when the infant cries. Based on this assessment finding, which conclusion should the nurse draw?
- A. That no action is required.
- B. The head of the bed needs to be lowered.
- C. The infant needs to be placed on NPO status.
- D. The primary health care provider should be notified immediately.
Correct Answer: A
Rationale: A bulging anterior fontanel in an infant when crying is a normal finding, as crying increases intracranial pressure temporarily. This does not indicate a pathological condition requiring immediate intervention. Lowering the head of the bed or placing the infant on NPO status is not warranted, and notifying the primary health care provider is unnecessary unless other signs of increased ICP, such as persistent bulging at rest, irritability, or lethargy, are present.
The nurse is creating a discharge plan for a postoperative client who had a unilateral adrenalectomy. What area of instruction should the nurse include in the plan to minimize the client's risk for injury?
- A. Teaching the client to maintain a diabetic diet
- B. Encouraging the adoption of a realistic exercise routine
- C. Providing a detailed list of the early signs of a wound infection
- D. Explaining the need for lifelong replacement of all adrenal hormones
Correct Answer: C
Rationale: A client who had a unilateral adrenalectomy (one adrenal gland was removed) will be placed on corticosteroids temporarily to avoid a cortisol deficiency; lifelong replacement is not necessary. Corticosteroids will be gradually weaned in the postoperative period until they are discontinued. Also, because of the anti-inflammatory properties of corticosteroids produced by the adrenals, clients who undergo an adrenalectomy are at increased risk of developing wound infections. Because of this increased risk of infection, it is important for the client to know measures to prevent infection, early signs of infection, and what to do if an infection seems to be present.
A client has had a nasointestinal (NI) tube in place for 24 hours. Which assessment finding indicates that the tube is properly located in the intestine?
- A. Bowel sounds are absent.
- B. The client denies being nauseous.
- C. Aspirate from the tube has a pH of 7.
- D. The abdominal x-ray indicates that the end of the tube is above the pylorus.
Correct Answer: C
Rationale: The nasogastric (NG) or NI tube is used to decompress the intestine and correct a bowel obstruction. Nausea should subside as decompression is accomplished. The pH of the gastric fluid is acidic, and the pH of the intestinal fluid is alkaline (7 or higher). Although bowel sounds will be abnormal in the presence of obstruction, the presence or absence of bowel sounds is not associated with the location of the tube. The end of the tube should be located in the intestine (below the pylorus). Location of the tube can also be determined by radiographs.
The nurse is caring for a child diagnosed with Reye's syndrome. The nurse monitors for manifestations of which condition associated with this syndrome?
- A. Protein in the urine
- B. Symptoms of hyperglycemia
- C. Increased intracranial pressure
- D. A history of a staphylococcus infection
Correct Answer: C
Rationale: Reye's syndrome is an acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver. Intracranial pressure and encephalopathy are major problems associated with Reye's syndrome. Protein is not present in the urine. Reye's syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this disease.
A client who underwent peripheral arterial bypass surgery 16 hours ago reports that there is increasing pain in the leg that worsens with movement and is accompanied by paresthesias. Based on these data, which action should the nurse take?
- A. Call the primary health care provider.
- B. Administer an opioid analgesic.
- C. Apply warm moist heat for comfort.
- D. Apply ice to minimize any developing swelling.
Correct Answer: A
Rationale: Compartment syndrome is characterized by increased pressure within a muscle compartment caused by bleeding or excessive edema. It compresses the nerves in the area and can cause vascular compromise. The classic signs of compartment syndrome are pain at rest that intensifies with movement and the development of paresthesias. Compartment syndrome is an emergency, and the primary health care provider is notified immediately because the client could require an emergency fasciotomy to relieve the pressure and restore perfusion.