Practice 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?
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Correct Answer:
Auscultating the rate and characteristics of the child's heart sounds
Rationale:
🫀 The top priority in a child with acute rheumatic fever (ARF) is cardiac assessment, particularly auscultating for murmurs, pericardial rubs, or signs of congestive heart failure, as carditis is the most serious and potentially life-threatening complication.
🫀 ARF can cause inflammation of the heart valves (especially the mitral and aortic valves), leading to rheumatic carditis, which may manifest as tachycardia, new or changing murmurs, gallops, or muffled heart sounds.
🫀 Prompt identification of cardiac involvement allows for early intervention, including anti-inflammatory treatment, antibiotics, and sometimes diuretics or cardiac monitoring.
🫀 The nurse’s immediate role post-admission is to identify any acute decompensation or signs of cardiac involvement to prevent serious complications.
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This question is from RN ATI Paediatrics Nur 223G Final Exam which contains 101 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Pediatrics
- Answer Choices: 4