Nokea
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.
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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.
The nurse is caring for a patient with acute dyspnea and is diagnosed with dilated cardiomyopathy. Which of the following information should the nurse include when teaching the patient about management of this disorder?
- A. Elevating the legs above the heart will help relieve angina.
- B. No more than two alcoholic drinks daily are recommended.
- C. Careful adherence to diet and medication regimen will prevent heart failure.
- D. Notify the health care provider about any symptoms of heart failure.
Correct Answer: D
Rationale: The patient should be instructed to notify the health care provider about any worsening of heart failure symptoms. Because dilated cardiomyopathy does not respond well to therapy, even patients with good adherence to therapy may have recurrent episodes of heart failure. The patient is instructed to avoid alcoholic beverages. Elevation of the legs above the heart will worsen symptoms (although this approach is appropriate for a patient with hypertrophic cardiomyopathy).
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.
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 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.