Nokea
A child with rheumatic fever is being admitted to the pediatric floor. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever?
- A. “Has your child complained of back pain?â€
- B. “Has your child complained of headaches?â€
- C. “Has your child had any nausea or vomiting?â€
- D. “Did your child have a sore throat or fever within the last 2 months?â€
Correct Answer: D
Rationale: A history of sore throat or fever within the last 2 months is significant as rheumatic fever often follows a streptococcal infection such as strep throat.
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Which is an important nursing consideration when chest tubes will be removed from a child?
- A. Explain that it is not painful.
- B. Explain that only a Band-Aid will be needed.
- C. Administer analgesics before the procedure.
- D. Expect bright red drainage for several hours after removal.
Correct Answer: C
Rationale: It is appropriate to prepare the child for the removal of chest tubes with analgesics. Short-acting medications can be used that are administered through an existing IV line. A sharp, momentary pain is felt. This should not be misrepresented to the child. A petroleum gauze, air-tight dressing will be needed, but it is not a pain-free procedure. Little or no drainage should be found on removal.
A client returns to the unit following a suprapubic prostatectomy. He has a three-way catheter in place with a continuous bladder irrigation infusing. Which assessment finding warrants immediate intervention by the nurse?
- A. True urinary output of 50ml/hr
- B. Lower abdominal tenderness
- C. Blood urine output with clots
- D. Urine leaking around the meatus
Correct Answer: D
Rationale: Urine leaking around the meatus may indicate catheter displacement or obstruction, requiring immediate attention to prevent complications.
The most common cardiac dysrhythmia in pediatrics is:
- A. Ventricular tachycardia
- B. Sinus bradycardia
- C. Supraventricular tachycardia
- D. First-degree heart block
Correct Answer: C
Rationale: SVT is the most common dysrhythmia in children.
A 2-year-old child is being treated for lead poisoning. Which of the following findings indicates the need for further intervention?
- A. Increased urine output
- B. Decreased hemoglobin levels
- C. Weight gain
- D. Improved developmental milestones
Correct Answer: B
Rationale: Lead poisoning can cause anemia, so a decrease in hemoglobin levels would indicate that further intervention is necessary.
Maltese crosses' are identified in the urinary sediments in
- A. Niemann Pick disease
- B. Gaucher disease
- C. Krabbe's disease
- D. Fabry disease
Correct Answer: D
Rationale: Fabry disease is characterized by the presence of 'Maltese crosses' in urinary sediments due to glycosphingolipid accumulation.