Nokea
The nurse establishes the nursing diagnosis of ineffective health maintenance related to lack of knowledge concerning long-term management of rheumatic fever when a patient who is recovering from rheumatic fever says which of the following statements?
- A. I will need to have monthly antibiotic injections for 10 years or longer.
- B. I will need to take Aspirin or ibuprofen to relieve my joint pain.
- C. I will call the doctor if I develop excessive fatigue or difficulty breathing.
- D. I will be immune to further episodes of rheumatic fever after this infection.
Correct Answer: D
Rationale: Patients with a history of rheumatic fever are more susceptible to a second episode. The other patient statements are correct and would not support the nursing diagnosis of ineffective health maintenance.
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Which of the following techniques should the nurse use to assess the patient with pericarditis for the presence of a pericardial friction rub?
- A. Auscultate with the stethoscope diaphragm at the lower left sternal border.
- B. Listen for a rumbling, low-pitched, systolic sound over the left anterior chest.
- C. Feel the precordial area with the palm of the hand to detect vibration with cardiac contraction.
- D. Ask the patient to stop breathing during auscultation to distinguish the sound from a pleural friction rub.
Correct Answer: A
Rationale: Pericardial friction rubs are heard best with the diaphragm at the lower left sternal border. Because dyspnea is one clinical manifestation of pericarditis, the nurse should time the friction rub with the pulse rather than ask the patient to stop breathing during auscultation. Friction rubs are not typically low pitched or rumbling and are not confined to systole. Rubs are not assessed by palpation.
Which of the following actions should the community health nurse include when planning ways to decrease the incidence of rheumatic fever?
- A. Immunize susceptible groups in the community with streptococcal vaccine.
- B. Teach community members to seek treatment for streptococcal pharyngitis.
- C. Educate about the importance of monitoring temperature when infections occur.
- D. Provide prophylactic antibiotics to people with a family history of rheumatic fever.
Correct Answer: B
Rationale: The incidence of rheumatic fever is decreased by treatment of streptococcal infections with antibiotics. Family history is not a risk factor for rheumatic fever. There is no immunization that is effective in decreasing the incidence of rheumatic fever. Education about monitoring temperature will not decrease the incidence of rheumatic fever.
The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE). Which of the following findings support this diagnosis?
- A. Fever, chills, and diaphoresis
- B. Urine output less than 30 ml/hour
- C. Petechiae of the buccal mucosa and conjunctiva
- D. Increase in pulse rate of 15 beats/minute with activity
Correct Answer: B
Rationale: Decreased renal perfusion caused by inadequate cardiac output will lead to poor urine output. Petechiae, fever, chills, and diaphoresis are symptoms of IE but are not caused by decreased cardiac output. An increase in pulse rate of 15 beats/minute is normal with exercise.
Which of the following findings in a patient with infective endocarditis (IE) is most important for the nurse to communicate to the health care provider?
- A. Generalized muscle aching
- B. Sudden onset left flank pain
- C. Janeway's lesions on the palms
- D. Temperature 38.1°C
Correct Answer: B
Rationale: Sudden onset of flank pain indicates possible embolization to the kidney and may require diagnostic testing such as a renal arteriogram and interventions to improve renal perfusion. The other findings are typically found in IE but do not require any new interventions.
The nurse is obtaining a health history from a patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which of the following questions by the nurse is best?
- A. Have you been to the dentist lately?
- B. Do you have a history of a heart attack?
- C. Is there a family history of endocarditis?
- D. Have you had any recent immunizations?
Correct Answer: A
Rationale: Dental procedures place the patient with a prosthetic mitral valve at risk for infective endocarditis (IE). Myocardial infarction (MI), immunizations, and a family history of endocarditis are not risk factors for IE.