Nokea
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.
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The nurse is caring for a patient with aortic stenosis and establishes a nursing diagnosis of acute pain related to decreased coronary blood flow. Which of the following interventions is best?
- A. Promote rest to decrease myocardial oxygen demand.
- B. Educate the patient about the need for anticoagulant therapy.
- C. Teach the patient to use sublingual nitroglycerin for chest pain.
- D. Elevate the head of the bed 60 degrees to decrease venous return
Correct Answer: A
Rationale: Rest is recommended to balance myocardial oxygen supply and demand and to decrease chest pain. The patient with aortic stenosis requires higher preload to maintain cardiac output, so nitroglycerin and measures to decrease venous return are contraindicated. Anticoagulation is not recommended unless the patient has atrial fibrillation.
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.
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.
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.
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.