Which of the following nursing diagnoses would best apply to a child during the acute phase of rheumatic fever?

Question

A) Disturbed sleep pattern related to hyperexcitability
B) Ineffective breathing pattern related to cardiomegaly
C) Risk for self-directed violence related to development of cerebral anoxia
D) Activity intolerance related to inability of heart to sustain extra workload

Answer 1

D
Feedback:
The course of rheumatic fever is about 6 to 8 weeks. Children are maintained on bed rest only during the acute phase of illness until the pulse rate returns to normal. Because pulse rate is a valuable sign of improvement, monitoring vital signs is essential during and following the acute phase. Obtain an apical pulse for a full minute for best results. Taking it while the child is asleep as well as when the child is awake helps to measure the effect of activity on the pulse rate; another way to judge inflammation is decreasing and the child's heart action is improving. Chorea occurs in some children with rheumatic fever; however, it is not known if this manifestation will disturb the child's sleep. Children with rheumatic fever may develop congestive heart failure; however, cardiomegaly is not a long-term effect of the disease. The child is not at risk for self-directed violence because cerebral anoxia is not a manifestation of the disease.