Nokea
The nurse is assessing a patient with infective endocarditis (IE). Which of the following findings should the nurse expect to assess?
- A. A new regurgitant murmur
- B. A pruritic rash on the trunk
- C. Involuntary muscle movement
- D. Substernal chest pain and pressure
Correct Answer: A
Rationale: New regurgitant murmurs occur in IE because vegetation on the valves prevents valve closure. Substernal chest discomfort, rashes, and involuntary muscle movement are clinical manifestations of other cardiac disorders such as angina and rheumatic fever.
You may also like to solve these questions
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 assessment information obtained by the nurse for a patient with aortic stenosis is most important to report to the health care provider?
- A. The patient complains of chest pain associated with ambulation.
- B. A loud systolic murmur is audible along the right sternal border.
- C. A thrill is palpable at the 2nd intercostal space, right sternal border.
- D. The point of maximum impulse (PMI) is at the left midclavicular line.
Correct Answer: A
Rationale: Chest pain occurring with aortic stenosis is caused by cardiac ischemia, and reporting this information would be a priority. A systolic murmur and thrill are expected in a patient with aortic stenosis. A PMI at the left midclavicular line is normal.
The nurse is conducting postoperative teaching with a patient who had a mitral valve replacement with a mechanical valve. Which of the following information should the nurse include in the teaching plan?
- A. Use of daily Aspirin for anticoagulation
- B. Correct method for taking the radial pulse
- C. Need for frequent laboratory blood testing
- D. Possibility of valve replacement in 7-10 years
Correct Answer: C
Rationale: Anticoagulation therapy with warfarin is needed for a patient with mechanical valves to prevent clotting on the valve; this will require frequent international normalized ratio (INR) testing. Daily Aspirin use will not be effective in reducing risk for clots on the valve. Mechanical valves are durable and would last longer than 7-10 years. Monitoring of the radial pulse is not necessary after valve replacement.
The nurse is caring for a patient who had an acute myocardial infarction (MI) 3 days prior and has symptoms of stabbing chest pain that increases with deep breathing. Which of the following actions should the nurse take first?
- A. Auscultate the heart sounds.
- B. Check the patient's oral temperature.
- C. Notify the patient's health care provider.
- D. Give the ordered acetaminophen.
Correct Answer: A
Rationale: The patient's clinical manifestations and history are consistent with pericarditis, and the first action by the nurse should be to listen for a pericardial friction rub. Checking the temperature, giving acetaminophen, and notifying the health care provider also are appropriate actions but would not be done before listening for a rub.
The nurse is assessing a patient who has mitral valve regurgitation. Which of the following findings should be communicated to the health care provider immediately?
- A. 4+ peripheral edema in both legs
- B. Crackles audible to the lung apices
- C. A palpable thrill felt over the left anterior chest
- D. A loud systolic murmur all across the precordium
Correct Answer: B
Rationale: Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure with pulmonary congestion and needs immediate interventions such as diuretics. A systolic murmur and palpable thrill would be expected in a patient with mitral regurgitation. Although 4+ peripheral edema indicates a need for a change in therapy, it does not need to be addressed urgently.