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NurseDive Free Nursing Practice Question
A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an antistreptolysin O (ASO) titer. The parent asks the nurse about the purpose of the test. Which of the following responses should the nurse make?
A. "This test will indicate if your child has rheumatic fever."
This test will not indicate if the child has rheumatic fever, as rheumatic fever is a complication of an untreated or inadequately treated streptococcal infection that affects the heart, joints, skin, and brain. Rheumatic fever is diagnosed based on clinical criteria, such as carditis, polyarthritis, chorea, erythema marginatum, and subcutaneous nodules.
B. "This test will confirm if your child had a recent streptococcal infection."
This test will confirm if the child had a recent streptococcal infection, as antistreptolysin O (ASO) is an antibody that the body produces in response to streptococcal bacteria. A high ASO titer indicates that the child was exposed to streptococcal bacteria within the past few weeks. A streptococcal infection can cause pharyngitis, tonsillitis, scarlet fever, or impetigo.
C. "This test will indicate if your child has a therapeutic blood level of an aminoglycoside."
This test will not indicate if the child has a therapeutic blood level of an aminoglycoside, as an aminoglycoside is a type of antibiotic that is used to treat serious bacterial infections. A therapeutic blood level of an aminoglycoside means that the drug is effective and safe in the body. A therapeutic blood level of an aminoglycoside is measured by a peak and trough level.
D. "This test will confirm if your child has immunity to streptococcal bacteria."
This test will not confirm if the child has immunity to streptococcal bacteria, as immunity to streptococcal bacteria means that the body can resist or fight the infection. Immunity to streptococcal bacteria can be acquired by natural exposure or vaccination. Immunity to streptococcal bacteria is measured by an antibody titer or a skin test.
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Full Explanation
Choice A: This test will not indicate if the child has rheumatic fever, as rheumatic fever is a complication of an untreated or inadequately treated streptococcal infection that affects the heart, joints, skin, and brain. Rheumatic fever is diagnosed based on clinical criteria, such as carditis, polyarthritis, chorea, erythema marginatum, and subcutaneous nodules.
Choice B: This test will confirm if the child had a recent streptococcal infection, as antistreptolysin O (ASO) is an antibody that the body produces in response to streptococcal bacteria. A high ASO titer indicates that the child was exposed to streptococcal bacteria within the past few weeks. A streptococcal infection can cause pharyngitis, tonsillitis, scarlet fever, or impetigo.
Choice C: This test will not indicate if the child has a therapeutic blood level of an aminoglycoside, as an aminoglycoside is a type of antibiotic that is used to treat serious bacterial infections. A therapeutic blood level of an aminoglycoside means that the drug is effective and safe in the body. A therapeutic blood level of an aminoglycoside is measured by a peak and trough level.
Choice D: This test will not confirm if the child has immunity to streptococcal bacteria, as immunity to streptococcal bacteria means that the body can resist or fight the infection. Immunity to streptococcal bacteria can be acquired by natural exposure or vaccination. Immunity to streptococcal bacteria is measured by an antibody titer or a skin test.
Similar Questions
A nurse is preparing to administer vaccines to a 1-year-old child. Which of the following vaccines should the nurse give? (Select two)
A. Measles, mumps, rubella (MMR)
Choice A reason: Measles, mumps, rubella (MMR): The MMR vaccine is recommended for children at 12-15 months of age. It protects against three serious diseases: measles, mumps, and rubella. The first dose is typically given at 12-15 months, with a second dose at 4-6 years. Measles can cause severe complications such as pneumonia and encephalitis. Mumps can lead to meningitis and hearing loss, while rubella can cause congenital rubella syndrome in pregnant women. Administering the MMR vaccine at the recommended age ensures that the child is protected from these potentially severe diseases.
B. Rotavirus (RV)
Choice B reason: Rotavirus (RV): This vaccine is given to infants at 2, 4, and possibly 6 months of age. It is not typically administered to a 1-year-old child as the series should be completed by 8 months. Rotavirus is a leading cause of severe diarrhea and dehydration in infants and young children. The vaccine is given orally and is highly effective in preventing rotavirus gastroenteritis. However, since the vaccine series is completed by 8 months, it is not appropriate for a 1-year-old child.
C. Human papillomavirus (HPV4)
Choice C reason: Human papillomavirus (HPV4): The HPV vaccine is recommended starting at 11-12 years of age. It is not suitable for a 1-year-old child. HPV is a common virus that can lead to certain types of cancers, including cervical cancer. The vaccine is most effective when given before exposure to HPV, which is why it is recommended for preteens. Administering the HPV vaccine to a 1-year-old would not be appropriate as it is not within the recommended age range.
D. Varicella (VAR)
Choice D reason: Varicella (VAR): The VAR vaccine is recommended for children at 12-15 months of age to protect against chickenpox. A second dose is given at 4-6 years. Chickenpox can cause an itchy rash, fever, and tiredness. In some cases, it can lead to severe skin infections, pneumonia, and encephalitis. Vaccinating at the recommended age ensures that the child is protected from these complications. The first dose at 12-15 months is crucial for building immunity against the varicella virus.
E. Diphtheria, tetanus and acellular pertussis (DTaP)
Choice E reason: Diphtheria, tetanus and acellular pertussis (DTaP): The DTaP vaccine is given in a series of five doses at 2, 4, 6, 15-18 months, and 4-6 years. The 4th dose is given at 15-18 months, not at 1 year. DTaP protects against three serious diseases: diphtheria, which can cause breathing problems and heart failure; tetanus, which causes painful muscle stiffness; and pertussis (whooping cough), which can lead to severe coughing spells and pneumonia. The timing of the doses is crucial for ensuring effective immunity, and the 1-year mark is not one of the recommended times for the DTaP vaccine.
Full Explanation
The correct answer is a. Measles, mumps, rubella (MMR) and d. Varicella (VAR).
Choice A reason:
Measles, mumps, rubella (MMR): The MMR vaccine is recommended for children at 12-15 months of age. It protects against three serious diseases: measles, mumps, and rubella. The first dose is typically given at 12-15 months, with a second dose at 4-6 years. Measles can cause severe complications such as pneumonia and encephalitis. Mumps can lead to meningitis and hearing loss, while rubella can cause congenital rubella syndrome in pregnant women. Administering the MMR vaccine at the recommended age ensures that the child is protected from these potentially severe diseases.
Choice B reason:
Rotavirus (RV): This vaccine is given to infants at 2, 4, and possibly 6 months of age. It is not typically administered to a 1-year-old child as the series should be completed by 8 months. Rotavirus is a leading cause of severe diarrhea and dehydration in infants and young children. The vaccine is given orally and is highly effective in preventing rotavirus gastroenteritis. However, since the vaccine series is completed by 8 months, it is not appropriate for a 1-year-old child.
Choice C reason:
Human papillomavirus (HPV4): The HPV vaccine is recommended starting at 11-12 years of age. It is not suitable for a 1-year-old child. HPV is a common virus that can lead to certain types of cancers, including cervical cancer. The vaccine is most effective when given before exposure to HPV, which is why it is recommended for preteens. Administering the HPV vaccine to a 1-year-old would not be appropriate as it is not within the recommended age range.
Choice D reason:
Varicella (VAR): The VAR vaccine is recommended for children at 12-15 months of age to protect against chickenpox. A second dose is given at 4-6 years. Chickenpox can cause an itchy rash, fever, and tiredness. In some cases, it can lead to severe skin infections, pneumonia, and encephalitis. Vaccinating at the recommended age ensures that the child is protected from these complications. The first dose at 12-15 months is crucial for building immunity against the varicella virus.
Choice E reason:
Diphtheria, tetanus and acellular pertussis (DTaP): The DTaP vaccine is given in a series of five doses at 2, 4, 6, 15-18 months, and 4-6 years. The 4th dose is given at 15-18 months, not at 1 year. DTaP protects against three serious diseases: diphtheria, which can cause breathing problems and heart failure; tetanus, which causes painful muscle stiffness; and pertussis (whooping cough), which can lead to severe coughing spells and pneumonia. The timing of the doses is crucial for ensuring effective immunity, and the 1-year mark is not one of the recommended times for the DTaP vaccine.
A nurse is providing discharge teaching to the parents of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parents indicates an understanding of the teaching?
A. "My son might have nausea and vomiting with hypoglycemia."
Nausea and vomiting are not common signs of hypoglycemia, which is a low blood glucose level. Nausea and vomiting are more likely to occur with hyperglycemia, which is a high blood glucose level, or with diabetic ketoacidosis, which is a life-threatening complication of diabetes.
B. "Sweating can occur with hyperglycemia."
Sweating is not a common sign of hyperglycemia, but rather a sign of hypoglycemia. Sweating occurs as a result of the activation of the sympathetic nervous system, which tries to raise the blood glucose level by releasing adrenaline and other hormones.
C. "The onset of low blood glucose usually occurs slowly."
The onset of low blood glucose usually occurs quickly, not slowly. Low blood glucose can be caused by taking too much insulin, skipping meals, exercising too much, or drinking alcohol. Low blood glucose can lead to confusion, seizures, coma, or death if not treated promptly.
D. "My son might complain of feeling shaky when he has a low blood glucose level."
Feeling shaky is a common sign of hypoglycemia, as the body tries to cope with the lack of glucose as an energy source. Feeling shaky can also be accompanied by other signs such as hunger, nervousness, dizziness, or weakness.
Full Explanation
Choice A: Nausea and vomiting are not common signs of hypoglycemia, which is a low blood glucose level. Nausea and vomiting are more likely to occur with hyperglycemia, which is a high blood glucose level, or with diabetic ketoacidosis, which is a life-threatening complication of diabetes.
Choice B: Sweating is not a common sign of hyperglycemia, but rather a sign of hypoglycemia. Sweating occurs as a result of the activation of the sympathetic nervous system, which tries to raise the blood glucose level by releasing adrenaline and other hormones.
Choice C: The onset of low blood glucose usually occurs quickly, not slowly. Low blood glucose can be caused by taking too much insulin, skipping meals, exercising too much, or drinking alcohol. Low blood glucose can lead to confusion, seizures, coma, or death if not treated promptly.
Choice D: Feeling shaky is a common sign of hypoglycemia, as the body tries to cope with the lack of glucose as an energy source. Feeling shaky can also be accompanied by other signs such as hunger, nervousness, dizziness, or weakness.
A nurse is planning care for an adolescent who has scoliosis and requires surgical intervention. Which of the following behaviors by the adolescent should the nurse anticipate because it is the most common reaction?
A. Body image changes
Body image changes are the most common reaction for an adolescent who has scoliosis and requires surgical intervention, as scoliosis affects the appearance and shape of the spine and torso. Body image changes can lead to low self-esteem, social isolation, depression, or anxiety.
B. Feelings of displacement
Feelings of displacement are not the most common reaction for an adolescent who has scoliosis and requires surgical intervention, as displacement means feeling out of place or unwanted in a certain situation or environment. Feelings of displacement can occur due to hospitalization, separation from peers or family, or lack of control over one's life.
C. Loss of privacy
Loss of privacy is not the most common reaction for an adolescent who has scoliosis and requires surgical intervention, as loss of privacy means having one's personal information or space exposed or invaded by others. Loss of privacy can occur due to frequent examinations, procedures, or interventions by health care providers or staff.
D. Identity crisis
Identity crisis is not the most common reaction for an adolescent who has scoliosis and requires surgical intervention, as identity crisis means having difficulty or confusion in defining one's self-concept or role in society. Identity crises can occur due to developmental changes, peer pressure, or cultural expectations.
Full Explanation
Choice A: Body image changes are the most common reaction for an adolescent who has scoliosis and requires surgical intervention, as scoliosis affects the appearance and shape of the spine and torso. Body image changes can lead to low self-esteem, social isolation, depression, or anxiety.
Choice B: Feelings of displacement are not the most common reaction for an adolescent who has scoliosis and requires surgical intervention, as displacement means feeling out of place or unwanted in a certain situation or environment. Feelings of displacement can occur due to hospitalization, separation from peers or family, or lack of control over one's life.
Choice C: Loss of privacy is not the most common reaction for an adolescent who has scoliosis and requires surgical intervention, as loss of privacy means having one's personal information or space exposed or invaded by others. Loss of privacy can occur due to frequent examinations, procedures, or interventions by health care providers or staff.
Choice D: Identity crisis is not the most common reaction for an adolescent who has scoliosis and requires surgical intervention, as identity crisis means having difficulty or confusion in defining one's self-concept or role in society. Identity crises can occur due to developmental changes, peer pressure, or cultural expectations.
