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Molly, with suspected rheumatic fever, is admitted to the pediatric unit. When obtaining the child's history, the nurseconsiders which information to be most important?
- A. A fever that started 3 days ago
- B. Lack of interest in food
- C. A recent episode of pharyngitis
- D. Vomiting for 2 days
Correct Answer: C
Rationale: A recent episode of pharyngitis is most important when obtaining the history of a child suspected of having rheumatic fever because rheumatic fever often develops as a complication of inadequately treated streptococcal pharyngitis. It is crucial to determine if there was a recent streptococcal infection to assess the likelihood of rheumatic fever developing. The other symptoms mentioned, such as fever, lack of interest in food, and vomiting, are important as well, but the connection with the recent episode of pharyngitis is more specifically related to the potential development of rheumatic fever in this case.
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The nurse has determined the rate of both the child's radial pulse and heart. What is the normal finding when comparing the two rates?
- A. Are the same
- B. Differ, with heart rate faster
- C. Differ, with radial pulse faster
- D. Differ, depending on quality and intensity
Correct Answer: A
Rationale: In a normal healthy individual, the rate of the radial pulse (peripheral pulse) and the heart rate (apical pulse) should be the same. This is because each heartbeat should result in a corresponding pulse felt at the radial artery in the wrist. The pulse is generated by the heart's contraction and the subsequent ejection of blood into the arteries, causing a wave of pressure that can be felt as the pulse. Therefore, in a healthy individual, the radial pulse rate should match the heart rate. If there is a significant difference between the two rates, it may indicate a cardiovascular abnormality or other underlying health condition that warrants further investigation.
The nurse is using the FLACC scale to rate the pain level in a 9-month-old. Which is the nurse's best response to the father's question of what the FLACC scale is?
- A. It estimates a child's level of pain utilizing vital sign information.
- B. It estimates a child's level of pain based on parents' perception.
- C. It estimates a child's level of pain utilizing behavioral and physical responses.
- D. It estimates a child's level of pain utilizing a numeric scale from 0 to 5.
Correct Answer: C
Rationale: The FLACC scale uses observable behavioral and physical responses (facial expression, leg movement, activity, cry, and consolability) to estimate pain.
Which of the following positions would be most appropriate for a patient with right-sided paralysis following a stroke?
- A. On the side with support to the back, with pillows to keep the body in alignment, hips slightly flexed, and hands tightly holding a rolled washcloth.
- B. On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
- C. On the back with two large pillows under the head, pillow under" the knees, and a footboard.
- D. On the back with no pillows used, with trochanter rolls and a footboard.
Correct Answer: B
Rationale: The most appropriate position for a patient with right-sided paralysis following a stroke is Option B - On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
You are examining an infant with multiple cutaneous hemangiomas; you suspect involvement of internal organs. The MOST common site of visceral involvement by hemangiomas is
- A. brain
- B. heart
- C. lung
- D. liver
Correct Answer: D
Rationale: Liver is the most common site of visceral involvement by hemangiomas.
For a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?
- A. "Client verbalizes feelings of anxiety."
- B. "Client doesn't guess at prognosis."
- C. "Client uses any effective method to reduce tension."
- D. "Client stops seeking information."
Correct Answer: C
Rationale: The expected outcome that would be appropriate for a client with newly diagnosed cancer experiencing anxiety related to the threat of death would be "Client uses any effective method to reduce tension." This outcome focuses on the client actively engaging in coping strategies to reduce their anxiety. It is important for the client to actively participate in managing their anxiety by utilizing various methods to promote relaxation and reduce tension. It is a more proactive and empowering goal compared to simply verbalizing feelings of anxiety or stopping seeking information. By actively using effective methods to reduce tension, the client is taking steps to improve their emotional well-being and cope with the anxiety related to the cancer diagnosis.