Nokea
A nurse assesses a client for signs of infective endocarditis. Which clinical manifestations should the nurse expect?
- A. Weight gain
- B. Night sweats
- C. Cardiac murmur
- D. Abdominal bloating
- E. Osler nodes
Correct Answer: B,C,E
Rationale: Clinical manifestations of infective endocarditis include night sweats, cardiac murmur, and Osler nodes. Weight gain and abdominal bloating are not typical; the latter is associated with heart transplant rejection.
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A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the priority nursing intervention?
- A. Oxygen saturation of 90%
- B. Dyspnea on exertion
- C. Mild systolic murmurs
- D. Upper extremity weakness
Correct Answer: B
Rationale: Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other manifestations do not directly indicate the progression of mitral valve stenosis.
After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for additional teaching?
- A. I'll be able to carry heavy loads after 6 months of rest
- B. I will have my teeth cleaned by my dentist in 2 weeks
- C. I must avoid eating foods high in vitamin K
- D. I will use an electric razor for shaving
Correct Answer: B
Rationale: Clients who have defective or repaired valves are at high risk for endocarditis. The client should avoid dental procedures for 6 months because of the risk for endocarditis. The other statements reflect correct understanding of post-surgery care.
A nurse prepares to discharge a client who has heart failure. Spice questions should the nurse ask to ensure the client's safety at home?
- A. Are your bedroom and bathroom on the first floor?
- B. What social support do you have at home?
- C. What is your typical daily diet?
- D. What spiritual beliefs may impact your recovery?
- E. Are you able to accurately weigh yourself at home?
Correct Answer: A,B,D
Rationale: To ensure safety, the nurse should assess structural barriers (e.g., bedroom/bathroom location), social support, and the ability to weigh daily for fluid monitoring. Diet and spiritual beliefs are relevant but not directly tied to safety.
A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, 'I know a transplant is my last chance, but I don't want to become a vegetable.' How should the nurse respond?
- A. Would you like to speak with a priest or chaplain?
- B. I will arrange for a psychiatrist to speak with you
- C. Do you want to come off the transplant list?
- D. Would you like information about advance directives?
Correct Answer: D
Rationale: This client is verbalizing a real concern about negative outcomes of the surgery. Providing information about advance directives allows the client to express their wishes and feel some control over their future. The other responses do not directly address the client's concerns or empower them.
A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take?
- A. Initiate oxygen therapy
- B. Hold the next dose of Imdur
- C. Instruct the client to drink water
- D. Administer PRN acetaminophen
Correct Answer: D
Rationale: The vasodilating effects of isosorbide mononitrate frequently cause headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen. The headache is not related to hypoxia or dehydration, so oxygen or water would not help. Holding the medication is not warranted.