Nokea
The following are examples of acquired heart disease. Select all that apply.
- A. Infective endocarditis
- B. Coarctation of the aorta
- C. Rheumatic fever (RF)
- D. Cardiomyopathy
Correct Answer: C
Rationale: Acquired heart diseases include conditions that develop after birth, such as infective endocarditis, rheumatic fever, cardiomyopathy, and Kawasaki disease. Coarctation of the aorta and transposition of the great vessels are congenital heart defects.
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A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention?
- A. Urinary output less than intake
- B. Bruising at the insertion site
- C. Slurred speech and confusion
- D. Discomfort in the left leg
Correct Answer: C
Rationale: Slurred speech and confusion may indicate a neurological complication, such as a stroke, which requires immediate intervention.
Family discharge teaching has been effective when the parent of a toddler diagnosed with Kawasaki disease (KD) states:
- A. The arthritis in her knees is permanent. She will need knee replacements.
- B. I will give her diphenhydramine (Benadryl) for her peeling palms and soles of her feet.
- C. I know she will be irritable for 2 months after her symptoms start.
- D. I will continue with high doses of Tylenol for her inflammation.
Correct Answer: C
Rationale: This statement indicates the parent understands that irritability may persist for about 2 months after symptom onset in KD.
The following features are more suggestive of biliary atresia rather than neonatal hepatitis in an infant 6 weeks of age:
- A. Hepatomegaly
- B. Prolonged INR (prothrombin time)
- C. Biopsy specimen showed proliferation of bile ductules, periportal fibrosis and bile lakes
- D. HillA scan reveals delayed uptake and excretion of the contrast material
Correct Answer: C
Rationale: Proliferation of bile ductules, periportal fibrosis, and bile lakes on biopsy are hallmark features of biliary atresia.
Symptoms in patients with aortic stenosis depend on the severity of the obstruction EXCEPT
- A. cardiomegaly
- B. pulmonary congestion
- C. weak pulses
- D. pale skin
Correct Answer: D
Rationale: Pale skin is not a typical symptom of aortic stenosis.
A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client plan of care?
- A. Continuous cardiac monitoring
- B. Perform passive range of motion
- C. Evaluate level of consciousness
- D. Assess lung sounds q4 hours.
Correct Answer: A
Rationale: Electrical injuries can cause cardiac arrhythmias, so continuous cardiac monitoring is critical to detect and manage any life-threatening complications.