Nokea
The nurse is conducting an admission health history with a patient with possible rheumatic fever. Which of the following questions is most pertinent to ask?
- A. Have you had a recent sore throat?
- B. Are you using any illegal IV drugs?
- C. Do you have any family history of congenital heart disease?
- D. Can you recall having any chest injuries in the last few weeks?
Correct Answer: A
Rationale: Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal infection. Although illicit intravenous (IV) drug use should be discussed with the patient before discharge, it is not a risk factor for rheumatic fever and would not be as pertinent when admitting the patient. Family history is not a risk factor for rheumatic fever. Chest injury would cause musculoskeletal chest pain rather than rheumatic fever.
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Which of the following actions should the community health nurse include when planning ways to decrease the incidence of rheumatic fever?
- A. Immunize susceptible groups in the community with streptococcal vaccine.
- B. Teach community members to seek treatment for streptococcal pharyngitis.
- C. Educate about the importance of monitoring temperature when infections occur.
- D. Provide prophylactic antibiotics to people with a family history of rheumatic fever.
Correct Answer: B
Rationale: The incidence of rheumatic fever is decreased by treatment of streptococcal infections with antibiotics. Family history is not a risk factor for rheumatic fever. There is no immunization that is effective in decreasing the incidence of rheumatic fever. Education about monitoring temperature will not decrease the incidence of rheumatic fever.
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 has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. Which of the following actions is best for the nurse to implement?
- A. Force fluids to 3000 ml to decrease fever and inflammation.
- B. Teach about deep, slow respirations to control the pain.
- C. Remind the patient to ask for the opioid pain medication every 4 hours.
- D. Position the patient in Fowler's position, leaning forward on the overbed table.
Correct Answer: D
Rationale: Sitting upright and leaning forward frequently will decrease the pain associated with pericarditis. Forcing fluids will not decrease the inflammation or pain. Taking deep respirations tends to increase pericardial pain. Opioids are not very effective at controlling pain caused by acute inflammatory conditions and are usually ordered PRN. The patient would receive scheduled doses of a nonsteroidal anti-inflammatory drug (NSAID).
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.
Cardiac tamponade is suspected in a patient who has acute pericarditis. Which of the following actions should the nurse implement to assess for the presence of pulsus paradoxus?
- A. Check the electrocardiogram (ECG) for variations in rate in relation to inspiration and expiration
- B. Note when Korotkoff sounds are audible during both inspiration and expiration.
- C. Auscultate for a pericardial friction rub that increases in volume during inspiration.
- D. Subtract the diastolic blood pressure (DBP) from the systolic blood pressure (SBP).
Correct Answer: B
Rationale: Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when Korotkoff sounds can be heard during only expiration and when they can be heard throughout the respiratory cycle. The other methods described would not be useful in determining the presence of pulsus paradoxus.