Nokea
The nurse is assessing a patient with mitral valve stenosis and hypoxemia. Which of the following findings should the nurse expect to assess?
- A. Diastolic murmur
- B. Peripheral edema
- C. Right upper quadrant tenderness
- D. Complaints of shortness of breath
Correct Answer: D
Rationale: The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting in hypoxemia and dyspnea. The other findings also may be associated with mitral valve disease, but are not indicators of possible hypoxemia.
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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.
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 caring for a patient with infective endocarditis of the tricuspid valve. Which of the following findings should the nurse plan to monitor for the presence of endocarditis in the patient?
- A. Dyspnea
- B. Flank pain
- C. Hemiparesis
- D. Splenomegaly
Correct Answer: A
Rationale: Embolization from the tricuspid valve would cause symptoms of pulmonary embolus. Flank pain, hemiparesis, and splenomegaly would be associated with embolization from the left-sided valves.
The nurse is admitting a patient with possible acute pericarditis. Which of the following diagnostic assessments should the nurse plan to teach the patient about?
- A. Electrolyte levels
- B. Echocardiography
- C. Daily blood cultures
- D. Cardiac catheterization
Correct Answer: B
Rationale: Echocardiograms are useful in detecting the presence of the pericardial effusions associated with pericarditis. Blood cultures are not indicated unless the patient has evidence of sepsis. Cardiac catheterization is not a diagnostic procedure for pericarditis. Electrolyte levels are not helpful in making a diagnosis of pericarditis.
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.