Nokea
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.
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The nurse is caring for a patient with rheumatic fever who has subcutaneous nodules, erythema marginatum, and polyarthritis. Which of the following nursing diagnoses best reflects these findings?
- A. Activity intolerance related to physical deconditioning (arthralgia)
- B. Risk for infection as evidenced by immunosuppression
- C. Chronic pain related to injury agent (permanent joint fixation)
- D. Risk for impaired skin integrity evidenced by pressure over bony prominence
Correct Answer: A
Rationale: The patient's joint pain will lead to difficulty with activity. The skin lesions seen in rheumatic fever are not open or pruritic and thus do not pose a high risk for infection. Although acute joint pain will be a problem for this patient, joint inflammation is a temporary clinical manifestation of rheumatic fever and is not associated with permanent joint changes.
The nurse is caring for a patient who is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. When explaining the advantage of valvuloplasty instead of valve replacement to the patient, which of the following information should the nurse include?
- A. Biological replacement valves require the use of immunosuppressive drugs.
- B. Mechanical mitral valves require replacement approximately every 5 years.
- C. Lifelong anticoagulant therapy is needed after mechanical valve replacement.
- D. Ongoing cardiac care by a health care provider is unnecessary after valvuloplasty.
Correct Answer: C
Rationale: Long-term anticoagulation therapy is needed after mechanical valve replacement, and this would restrict decisions about career and childbearing in this patient. Mechanical valves are durable and last longer than 5 years. All valve repair procedures are palliative, not curative, and require lifelong health care. Biological valves do not activate the immune system, and immunosuppressive therapy is not needed.
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 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 conducting discharge teaching about the need for prophylactic antibiotics when having dental procedures. This teaching would be provided to a patient with which of the following diagnoses?
- A. Acute myocardial infarction
- B. Exacerbation of heart failure
- C. Mechanical mitral valve replacement
- D. Rheumatic fever after a streptococcal infection
Correct Answer: C
Rationale: Current guidelines recommend the use of prophylactic antibiotics before dental procedures for patients with prosthetic valves to prevent infective endocarditis (IE). The other patients are not at risk for IE.