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A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition?
- A. Dyspnea
- B. Heart murmur
- C. Macular rash
- D. Hemorrhage
Correct Answer: B
Rationale: A new or changed heart murmur is a common sign of valve involvement in infective endocarditis, indicating a complication such as valve damage or regurgitation. Dyspnea is more commonly associated with respiratory or cardiac conditions not directly related to infective endocarditis. A macular rash is not a typical symptom of infective endocarditis, suggesting other conditions like infectious diseases. Hemorrhage is not a direct complication of infective endocarditis but may occur due to factors such as anticoagulant therapy or underlying bleeding disorders.
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When assessing a client's skin turgor, a nurse should:
- A. Grasp a fold of the skin on the chest under the clavicle, release it, and note the depth of the impression
- B. Check skin elasticity on the back of the hand
- C. Press on the skin over the abdomen
- D. Measure skin turgor on the lower leg
Correct Answer: A
Rationale: Correct answer: When assessing a client's skin turgor, a nurse should grasp a fold of the skin on the chest under the clavicle, release it, and note the depth of the impression. This method is reliable for evaluating hydration status as it is less influenced by age-related skin changes or adipose tissue. Choice B, checking skin elasticity on the back of the hand, is not the preferred method for assessing skin turgor. Choice C, pressing on the skin over the abdomen, is not a standard location for assessing skin turgor. Choice D, measuring skin turgor on the lower leg, is not a recommended site for assessing skin turgor in clinical practice.
When assessing a client's IV for infiltration, which finding would be unexpected for the nurse?
- A. The area around the infusion site feels warm to the touch.
- B. The infusion site is swollen and cool to the touch.
- C. The infusion line does not flush properly.
- D. There is no blood return in the infusion line.
Correct Answer: A
Rationale: The correct answer is A. Warmth around the infusion site is not an expected finding with infiltration. Infiltration typically presents with swelling and coolness due to the fluid leaking into the surrounding tissue. Choices B, C, and D are incorrect because swelling, coolness, and difficulty flushing the line, as well as lack of blood return, are commonly associated with infiltration.
A client is admitted with a diagnosis of left-sided heart failure. Which assessment finding would be most concerning?
- A. Peripheral edema
- B. Crackles in the lungs
- C. Jugular vein distention
- D. Hepatomegaly
Correct Answer: B
Rationale: The correct answer is B: Crackles in the lungs. Crackles in the lungs indicate pulmonary congestion, a serious complication of left-sided heart failure. The presence of crackles suggests fluid accumulation in the lungs, impairing gas exchange and potentially leading to respiratory distress. Immediate intervention is necessary to prevent worsening respiratory function. Choices A, C, and D are incorrect: Peripheral edema is a common finding in heart failure but may not be as acutely concerning as pulmonary congestion. Jugular vein distention is associated with right-sided heart failure, not left-sided heart failure. Hepatomegaly is often seen in liver conditions and right-sided heart failure, not specifically left-sided heart failure.
A healthcare professional is caring for a group of clients on a medical-surgical unit. Which of the following clients is at increased risk for body-image disturbances?
- A. A client who had a laparoscopic appendectomy
- B. A client who had a mastectomy
- C. A client who had a left above-the-knee amputation
- D. A client who had a cardiac catheterization
Correct Answer: C
Rationale: Clients who have undergone significant visible body changes, like amputation, are at increased risk for body-image disturbances. Amputation can have a profound impact on self-image and body perception due to the visible structural alteration. While conditions like laparoscopic appendectomy, mastectomy, and cardiac catheterization may also affect body image, they are less likely to cause significant disturbances compared to visible changes like amputation.
The LPN/LVN is assisting with the care of a client who has had a stroke. Which intervention is most important to include in the client's plan of care to prevent joint contractures?
- A. Encourage the client to perform active range-of-motion exercises.
- B. Use pillows to keep the client's extremities in a functional position.
- C. Place the client in a prone position for 30 minutes each day.
- D. Perform passive range-of-motion exercises on the affected side.
Correct Answer: B
Rationale: Using pillows to keep the client's extremities in a functional position is crucial in preventing joint contractures. This intervention helps maintain proper alignment of the joints and reduces the risk of contractures by preventing prolonged positioning that can lead to muscle shortening. Encouraging the client to perform active range-of-motion exercises (Choice A) is beneficial for maintaining mobility but may not be the most important intervention to prevent joint contractures. Placing the client in a prone position for 30 minutes each day (Choice C) can be helpful for preventing pressure ulcers but is not directly related to preventing joint contractures. Performing passive range-of-motion exercises on the affected side (Choice D) can aid in maintaining joint flexibility but may not be as crucial as using pillows to prevent joint contractures.