Nokea
Which assessment finding in a client with endocarditis requires immediate action?
- A. Splinter hemorrhages under nails
- B. Mild joint pain
- C. New heart murmur
- D. Fatigue after activity
Correct Answer: C
Rationale: A new heart murmur may indicate valve damage or worsening infection, requiring urgent evaluation.
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The client with heart failure asks why they need to limit sodium intake. What is the best response?
- A. Sodium causes your heart to beat faster.
- B. Sodium makes your body retain fluid.
- C. Sodium increases your blood sugar.
- D. Sodium weakens your heart muscle.
Correct Answer: B
Rationale: Sodium promotes fluid retention, which increases cardiac workload in heart failure.
The client with endocarditis is at risk for which complication?
- A. Embolism
- B. Hypoglycemia
- C. Osteoarthritis
- D. Pancreatitis
Correct Answer: A
Rationale: Endocarditis can cause vegetations on heart valves, which may break off and form emboli.
The nurse is assessing the client diagnosed with long-term arterial occlusive disease. Which assessment data support the diagnosis?
- A. Hairless skin on the legs.
- B. Brittle, flaky toenails.
- C. Petechiae on the soles of feet.
- D. Nonpitting ankle edema.
Correct Answer: A
Rationale: Hairless skin (A) indicates chronic ischemia in PAD. Brittle nails (B) are nonspecific, petechiae (C) suggest bleeding, and nonpitting edema (D) is unrelated (pitting edema is venous).
Which client behavior would be a causative factor for developing Buerger's disease (thromboangiitis obliterans)?
- A. Drinking alcohol daily.
- B. Eating a high-fat diet.
- C. Chewing tobacco.
- D. Inhaling gasoline fumes.
Correct Answer: C
Rationale: Buerger’s disease is strongly linked to tobacco use, including chewing tobacco (C), which causes vascular inflammation. Alcohol (A), high-fat diet (B), and gasoline fumes (D) are not primary causes.
When the nurse is planning the client's postoperative care, which action is the highest priority?
- A. Providing the client with protein-rich foods
- B. Ambulating the client frequently
- C. Monitoring for wound infection
- D. Assessing for frequent leg cramping
Correct Answer: C
Rationale: Monitoring for wound infection is critical post-surgery to prevent complications and ensure healing.