Nokea
Which of the following assessment information obtained by the nurse for a patient with aortic stenosis is most important to report to the health care provider?
- A. The patient complains of chest pain associated with ambulation.
- B. A loud systolic murmur is audible along the right sternal border.
- C. A thrill is palpable at the 2nd intercostal space, right sternal border.
- D. The point of maximum impulse (PMI) is at the left midclavicular line.
Correct Answer: A
Rationale: Chest pain occurring with aortic stenosis is caused by cardiac ischemia, and reporting this information would be a priority. A systolic murmur and thrill are expected in a patient with aortic stenosis. A PMI at the left midclavicular line is normal.
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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 caring for a patient who has had recent cardiac surgery and develops pericarditis, with symptoms of chest pain at a level 6 (0-10 scale) with deep breathing. Which of the following prescribed PRN medications should the nurse administer?
- A. Fentanyl 2 mg IV
- B. Morphine sulphate 6 mg IV
- C. Ibuprofen 800 mg PO
- D. Acetaminophen 650 mg PO
Correct Answer: C
Rationale: The pain associated with pericarditis is caused by inflammation, so nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are most effective. Opioid analgesics are usually not used for the pain associated with pericarditis.
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.
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.
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.