Nokea
Select below the 4 findings that are most concerning at this time.
- A. controlled hypertension, hypercholesterolemia, and mitral valve prolapse and regurgitation.
- B. T 100.4 F (38 C),
- C. Thin, brown longitudinal lines on
several nail beds. - D. 2 teeth extracted 3 weeks ago;
- E. general malaise, fever and chills, night sweats, fatigue,
and poor appetite. - F. erythematous macular lesions on both palms
Correct Answer: B,C,D,F
Rationale: This client has multiple findings concerning for infective endocarditis (IE), which occurs when an infectious organism enters the
innermost layer of the heart (ie, endocardium) and forms a vegetation on a heart valve. Findings concerning for IE include:
• Recent tooth extraction: Dental procedures (eg, tooth extraction) increase the risk for infectious organisms entering the
bloodstream, potentially leading to IE. Other risk factors include a history of IV drug use, presence of a distant infection
(eg, leg cellulitis), or presence of a prosthetic heart valve
• Fever: Elevated temperature is a sign of infection, which is a common finding in clients with IE.
• Nontender, erythematous, macular lesions on the palms or soles (Janeway lesions): Janeway lesions are
characteristic of IE. They occur when turbulent blood flow through the heart valves causes pieces of endocardial
vegetation to break off, forming microemboli that travel through the arteries to end-capillaries and block blood flow.
• Nonblanching, thin, red/dark longitudinal lines under the nail beds (splinter hemorrhages): Like Janeway lesions,
splinter hemorrhages are caused by microemboli that break off from vegetative lesions in the heart and travel through the
arteries to end-capillaries and block blood flow.
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The nurse has reviewed the information from the Laboratory Results. The client is transferred to an inpatient care facility. Which of the following orders should the nurse expect for the client? Select all that apply
- A. insulin IV infusion
- B. continuous cardiac monitoring
- C. hourly finger-stick blood glucose level
- D. 5% dextrose in 0.9% sodium chloride IV infusion
- E. rectal sodium polystyrene sulfonate
- F. strict intake and output monitoring
Correct Answer: A,B,C,G
Rationale: Management of diabetic ketoacidosis (DKA) initially focuses on IV fluid resuscitation to reverse hypovolemia and then correction of
hyperglycemia, electrolyte abnormalities, and acid-base imbalance. Appropriate interventions include:
• Continuous insulin IV infusion to correct hyperglycemia. IV insulin has a more rapid onset of action than subcutaneous insulin, whic
allows faster and more precise management of the blood glucose level (Option 1).
• Continuous cardiac monitoring to detect dyshythmias related to metabolic acidosis or electrolyte abnormalities (Option 2).
• Hourly finger-stick blood glucose level checks to monitor for treatment effectiveness and detect any hypoglycemia related to the
insulin infusion (Option 3).
• Isotonic IV fluid (eg, 0.9% sodium chloride) to replace fluid losses and strict intake and output monitoring to evaluate the
effectiveness of fluid resuscitation and monitor for signs of acute kidney injury (Option 6).
• Frequent monitoring of arterial blood gas levels and electrolyte levels.
For each finding below, click to specify if the finding is consistent with the disease process of infective endocarditis, pericarditis, or pneumonia. Each finding may support more than one disease process.
- A. New or worsening cardiac murmurs
- B. Muffled heart sounds on auscultation
- C. Splinter hemorrhages on the nail beds
- D. Presence of flu-like symptoms and fever
- E. Substernal pain that is aggravated by inspiration
Correct Answer:
Rationale: Infective endocarditis occurs when an infectious organism forms a vegetation on a heart valve (interior of the heart). Clients
often have nonspecific symptoms of infection such as fever, flu-like symptoms (myalgia, arthralgia), and malaise.
Vegetation on a heart valve makes the valve dysfunctional, creating a new or worsening cardiac murmur. Pieces of
endocardial vegetation can break off, forming microemboli that travel through the arteries to end-capillaries and block blood
flow (eg, splinter hemorrhages on the nail beds), and cause erythematous macular lesions on the palms or soles (Janeway
lesions).
Acute pericarditis is inflammation of the membranous sac surrounding the exterior of the heart (pericardium), which often
causes an increased fluid in the pericardial cavity (ie, pericardial effusion). If pericardial effusions accumulate rapidly or are
very large, they may compress the heart, altering the mechanics of the cardiac cycle (ie, cardiac tamponade). Clinical
manifestations of pericarditis include muffled heart sounds on auscultation, presence of flu-like symptoms and fever, and
substernal pain that is aggravated by inspiration (ie, pleuritic chest pain). Pericardial friction rub, a superficial scratching or
squeaky sound, may be present, but cardiac murmurs are not present (no valve involvement) and embolic phenomena are
uncommon.
Pneumonia is an infection in the lungs that results in the production of cellular debris and purulent secretions that obstruct the
alveoli and prevent adequate oxygenation. Clinical manifestations include the presence of flu-like symptoms and fever,
pleuritic chest pain, tachycardia, low capillary oxygen saturation (SpO2), crackles, and productive cough with purulent
sputum.
The nurse is planning care with the registered nurse. For each potential prescription, click to specify if the prescription is expected or unexpected for the initial care of the client.
- A. Continuous cardiac monitoring
- B. Frequent electrolyte monitoring
- C. Continuous regular insulin IV infusion
- D. Hourly finger-stick blood glucose checks
- E. Nebulized albuterol breathing treatments
- F. 5% dextrose in 0.9% sodium chloride IV infusion
Correct Answer:
Rationale: The priority intervention for diabetic ketoacidosis (DKA) is fluid resuscitation to restore fluid volume and increase organ perfusion. Fluid
resuscitation also treats hypovolemic shock and normalizes electrolyte and blood glucose levels via hemodilution. When planning initial care
for a client with DKA, prescriptions that would be expected include:
• Continuous cardiac monitoring due to the risk for dyshythmias caused by potassium imbalances
• Frequent electrolyte monitoring to assess for electrolyte imbalances from rapid fluid and electrolyte shifts that occur with IV fluid and
insulin administration
• Continuous regular insulin IV infusion of a short-acting insulin used to transport blood glucose into the cells to treat hyperglycemia
and stop ketosis (Glucose levels should be lowered slowly because a rapid decrease in glucose can cause cerebral edema.)
• Hourly finger-stick blood glucose to titrate the insulin dose and monitor glucose levels
Unexpected prescriptions for the initial care of a client with DKA include:
• Albuterol, a beta-adrenergic agonist used to prevent/treat bronchospasm that has the additional effect of decreasing serum potassium
levels. Because the client with DKA is already at risk for hypokalemia due to net potassium deficiency, albuterol increases the client's
risk for dysrhythmias.
• 5% dextrose in 0.9% sodium chloride IV infusion, a sugar-containing solution used to increase blood glucose levels, which would
worsen hyperglycemia
The nurse has reviewed the information from the Nurses' Notes, Vital Signs, and Laboratory Results.The nurse is reviewing the client's response to potassium-lowering therapies. Which finding is unexpected and requires follow-up by the
nurse?
- A. Blood glucose level and diaphoresis
- B. Blood pressure and heart rate
- C. Crackles and peripheral edema
- D. Serum potassium level
Correct Answer: A
Rationale: Treatment for hyperkalemia includes administration of calcium gluconate, furosemide, albuterol nebulizer, and insulin with dextrose. These
therapies may cause rapid shifts in fluid volume, blood glucose, and serum electrolytes. Insulin shifts available glucose and potassium into
the cell, lowering serum potassium levels; however, too much insulin and not enough dextrose cause hypoglycemia (eg, blood glucose 50
mg/dL [2.7 mmol/L]). Clients with kidney disease have an increased risk of hypoglycemia because insulin may accumulate.
The nurse should understand that a low blood glucose level and symptoms suspicious for hypoglycemia (eg, diaphoresis) require follow-u
to prevent seizures, coma, and death due to lack of circulating glucose (Option 1). This client requires an additional dose of dextrose.
(Option 2) This client's blood pressure is 146/88 mm Hg and heart rate is within normal limits. This is an improvement from the initial blood
pressure and represents a therapeutic response to furosemide administration. Blood pressure should be lowered slowly to avoid hypotensior
For each finding below, click to specify if the finding is consistent with the disease process of autism spectrum disorder, obsessive-compulsive disorder, or separation anxiety disorder. Each finding may support more than one disease process.
- A. Ritualized pattern of behavior
- B. Disinterest in social interaction
- C. Lack of spontaneous eye contact
- D. Restricted, fixated thoughts or interests
Correct Answer:
Rationale: Symptoms of autism spectrum disorder (ASD) range in severity from one individual to another. Clients often demonstrate a
ritualized pattern of behavior, resulting in distress and self-harm (eg, hitting the head) in response to changes in routine or
environment. Other manifestations include disinterest in social interaction, deficiency in verbal and nonverbal
communication (eg, lack of spontaneous eye contact or facial expressions), and restricted, fixated thoughts or interests
(eg, attached to unusual objects).
Obsessive-compulsive disorder (OCD) is characterized by obsessions (ie, restricted, fixated thoughts, impulses, or
images) and compulsions (ie, ritualistic, repetitive behaviors performed to reduce anxiety or prevent an adverse event).
These compulsions are time consuming and cause significant distress. In contrast to those with OCD, clients with ASD are not
bothered about their preoccupations or mannerisms and do not desire to change. Clients with OCD do not have issues with
social interaction or social-emotional reciprocity (eg, poor eye contact).