Chapter 24
The school nurse is providing care to a child with a sore throat. With any sign of throat infection, the nurse stresses which of the following? Warm, salt water gargling Obtaining a throat culture Fluid increase to 2500cc Administering antiseptic lozenges
obtaining a throat culture
he nurse determines that a client recently diagnosed with subacute bacterial endocarditis understands discharge teaching upon which client statement? "I have to call my doctor so I can get antibiotics before seeing the dentist." "I need a referral to a dietician to understand a low-sodium diet." "Can I take the antibiotics as a pill now?" "If I quit smoking, it will help the endocarditis."
"I have to call my doctor so I can get antibiotics before seeing the dentist."
When teaching a client with rheumatic carditis and a history of recurrent rheumatic fever, which statement by the client indicates that teaching has been successful? "I will avoid any kind of activity." "I may have to take prophylactic antibiotics for up to 10 years." "I will avoid milk, yogurt, and other dairy products." "I will take a nonsteroidal anti-inflammatory medication every day."
"I may have to take prophylactic antibiotics for up to 10 years."
The nurse is educating a client about the care related to a new diagnosis of mitral valve prolapse. What statement made by the client demonstrates understanding of the teaching? "I can get a tattoo at a local parlor." "I will take antibiotics before getting my teeth cleaned." "I can get my tongue pierced at a store in the shopping mall." "I will avoid cafstore in the shopping mall." "I will avoid caffeine, alcohol, and smoking."
"I will avoid caffeine, alcohol, and smoking."
A nurse is teaching a client who is awaiting a heart transplant. Which statement indicates the client understands what is required to help minimize rejection? "I will need to take three different types of medications for the rest of my life to help prevent rejection." "There is no risk of rejection if the donor heart is an exact match." "I will need medication following surgery to prevent rejection, but if my body does not reject the new heart, I will not have to take any medication at home." "I will receive medication before and during surgery, which will eliminate the risk of rejection."
"I will need to take three different types of medications for the rest of my life to help prevent rejection."
The nurse instructs a client recovering from mechanical valve replacement surgery. Which client statement indicates that teaching has been effective? "I will not drive until informed by my health care provider." "I have a low risk of developing an infection in my heart." "I will not need to take anticoagulant medication every day." "I can play soccer in a week or two."
"I will not drive until informed by my health care provider."
A nurse is caring for a client newly diagnosed with mitral valve prolapse. The health care provider indicates the client has probably had this condition for years. What factor is important for the nurse to consider when teaching the client about valvular disease? "The client's religion may prohibit the client from seeking medical attention." "The client needs premium insurance to cover the cost of medications." "The client with mitral valve prolapse probably had no health symptoms." "The client may have to wear antiembolism stocking to help with venous return."
"The client with mitral valve prolapse probably had no health symptoms."
A 6-year-old child has been diagnosed with growth hormone deficiency. The child's mother requests more information about this condition. Which statements should be included in the nurse's response? Select all that apply. "The majority of children who have this condition are born of normal weight and length." "There are several potential causes of this condition." "Your child most likely does not eat adequate amounts of protein." "Most children with this condition are nutritionally deprived." "This condition is most likely related to dwarfism in past generations of your family."
"The majority of children who have this condition are born of normal weight and length." "There are several potential causes of this condition."
A client presents to the emergency department reporting chest pain. Which order should the nurse complete first? Aspirin 325 mg orally 2 L oxygen via nasal cannula 12-lead ECG Troponin level
12 lead ECG
When collecting data on a child diagnosed with diabetes mellitus, the nurse notes that the child has had weight loss and other symptoms of the disease. The nurse would anticipate which finding in the child's fasting glucose levels? 140 mg/dl 100 mg/dl 60 mg/dl 220 mg/dl
220
The nurse is caring for a five-client assignment on a cardiac unit. In caring for which client would the nurse be most correct to assess for an effusion? A client with aortic stenosis A client with mitral valve prolapse A client with chest trauma A client with chest pain
A client with chest trauma
The nurse is auscultating the heart of a client diagnosed with mitral valve prolapse. Which is often the first and only manifestation of mitral valve prolapse? Dizziness An extra heart sound Fatigue Syncope
An extra heart sound
Which would the nurse stress as a periodic lifelong necessity for a client managing infective endocarditis? Antihypertensive medication Potassium replacement Exercise regimen Antibiotic therapy
Antibiotic therapy
A nurse is caring for a client receiving warfarin therapy following a mechanical valve replacement. The client had a prothrombin time and International Normalized Ratio (INR) drawn before breakfast. The laboratory report shows the client's INR reading was 4. What is the nurse's first priority ? Assess the client for bleeding and notify the health care provider of the results. Be prepared to administer an I.M. vitamin K injection and notify the healthcare provider of the results. Notify the health care provider to request an increase in the warfarin dose. Notify the next nurse on afternoon shift to hold the evening dose of warfarin.
Assess the client for bleeding and notify the health care provider of the results.
A nurse is caring for a client who had an aortic balloon valvuloplasty. The nurse should inspect the surgical insertion site closely for which complication(s)? Bleeding and wound dehiscence Thrombosis and infection Evisceration Bleeding and infection
Bleeding and infection
The nurse is caring for a patient diagnosed with pericarditis. What serious complication should this patient be monitored for? Cardiac tamponade Left ventricular hypertrophy Decreased venous pressure Hypertension
Cardiac tamponade
Which nursing intervention should a nurse perform when a client with cardiomyopathy receives a diuretic? Allow unrestricted physical activity Maintain bed rest Check regularly for dependent edema Administer oxygen
Check regularly for dependent edema
Which nursing intervention should a nurse perform to reduce cardiac workload in a client diagnosed with myocarditis? Administer a prescribed antipyretic Maintain the client on bed rest Elevate the client's head Administer supplemental oxygen
Maintain the client on bed rest
A client with aortic regurgitation is admitted to the hospital. Which assessment findings would indicate left ventricular failure? Orthopnea, nausea, pedal edema Dyspnea, orthopnea, paroxysmal nocturnal dyspnea (PND) Dyspnea, distended jugular veins, orthopnea Distended jugular veins, pedal edema, nausea
Dyspnea, orthopnea, paroxysmal nocturnal dyspnea (PND)
The diagnosis of aortic regurgitation (AR) is confirmed by which of the following? Myocardial biopsy Echocardiography Cardiac catheterization Exercise stress testing
Echocardiography
A nurse is caring for a client with aortic stenosis whose compensatory mechanisms of the heart have begun to fail. The nurse will monitor the client carefully for which initial symptoms? Syncope, fever, vomiting Dizziness, nausea, diarrhea Nausea, vomiting, exertional fatigue Exertional dyspnea, orthopnea, pulmonary edema
Exertional dyspnea, orthopnea, pulmonary edema
The nurse is preparing a teaching plan for a 10-year-old girl with hyperthyroidism. What information would the nurse include in the plan? Describing surgery to remove an anterior pituitary tumor Showing her parents how to give DDAVP intranasally Teaching her parents to give injections of growth hormone Explaining about the radioactive iodine procedure
Explaining about the radioactive iodine procedure
In which type of cardiomyopathy does the heart muscle actually increase in size and mass weight, especially along the septum? Dilated Restrictive Arrhythmogenic right ventricular Hypertrophic
Hypertrophic
A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. Which client statement indicates to the nurse a need for additional teaching? "I should increase my fluid intake." "I should eat foods rich in protein." "I can still drink coffee and tea." "I'll enroll in an aerobic exercise program."
I can still drink coffee and tea."
A client who recently had a myocardial infarction develops pericarditis and complains of chest pain rated 6 (on a scale of 0-10) with deep breathing. Which ordered pro re nata medications is most appropriate for the nurse to administer? Morphine sulfate 6 mg IVP every 2-4 hours Fentanyl 2 mg intravenous pyelogram (IVP) every 2-4 hours Ibuprofen 800 mg PO every 8 hours Acetaminophen 650 mg PO every 4 hours
Ibuprofen 800 mg PO every 8 hours
A patient with a history of valvular disease has just arrived in the PACU after a percutaneous balloon valvuloplasty. Which intervention should the recovery nurse implement? Assess the patient's chest tube output. Evaluate the patient's endotracheal lip line. Monitor the patient's chest drainage. Keep the patient's affected leg straight.
Keep the patient's affected leg straight.
What is the most common cause of mitral stenosis? Degenerative stenosis Myocardial infarction Congestive heart failure Rheumatic endocarditis
Rheumatic endocarditis
The nurse is caring for a 4-year-old boy during a growth hormone stimulation test. Which task is priority in the care of this child? Monitoring intake and output. Providing a wet washcloth to suck. Monitoring blood glucose levels. Educating family about side effects.
Monitoring blood glucose levels.
The nurse is caring for a client with manifestations of dilated cardiomyopathy. When planning care, which consideration would the nurse make? Instruct client to avoid strenuous activity. Assess abdominal girth daily. Assist client to bathroom every 2 hours. Place bed in a high or semi-high Fowler's position as needed.
Place bed in a high or semi-high Fowler's position as needed.
Which intervention should the nurse include in the plan of care for a client with valvular heart disease who is experiencing pulmonary congestion? Take nitroglycerin if shortness of breath develops Report a weight gain of 3 pounds in 1 week Rest and sleep in a chair or sit in bed with head elevated Drink at least 2 L of fluid daily and monitor urine output
Rest and sleep in a chair or sit in bed with head elevated
A client comes to the clinic reporting fever, chills, and sore throat and is diagnosed with streptococcal pharyngitis. A nurse knows that early diagnosis and effective treatment is essential to avoid which preventable disease? Mitral stenosis Cardiomyopathy Pericarditis Rheumatic fever
Rheumatic fever
A nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, which finding should the nurse consider significant? Croup Rheumatic fever Medullary sponge kidney Severe staphylococcal infection
Rheumatic fever
A client with a myocardial infarction develops acute mitral valve regurgitation. The nurse knows to assess for which manifestation that would indicate that the client is developing pulmonary congestion? Tachycardia Shortness of breath Hypertension A loud, blowing murmur
SOB
A nurse is caring for a client with pericarditis and auscultates a pericardial friction rub. What action does the nurse ask the client to do to distinguish a pericardial friction rub from a pleural friction rub? The nurse has the client stand during auscultation. There is really no question to ask the client to tell the difference. The nurse places the client flat for at least 4 minutes. The nurse asks the client to hold the breath during auscultation.
The nurse asks the client to hold the breath during auscultation.
The nurse caring for a client with cardiomyopathy plans to have an education session with the client and the client's spouse about ways to improve cardiac output and reduce the workload of the heart. Which of the following instructions would help reduce preload? When resting, sit up with the legs down to pool blood in the legs. Avoid all physical and emotional stress. Lay flat in bed when resting so the heart does not have to pump against gravity. Adhere to a regular diet without restrictions.
When resting, sit up with the legs down to pool blood in the legs.
The nurse is preparing to administer warfarin to a client with a mechanical valve replacement. The client's international normalized ratio is 2.7. What action will the nurse take? Asses the client for abnormal bleeding. Prepare to administer vitamin K. Hold the medication and notify the HCP. Administer the medication as ordered.
administer the medication as ordered
While assessing a patient with pericarditis, the nurse cannot auscultate a friction rub. Which action should the nurse implement? Prepare to insert a unilateral chest tube. Notify the health care provider. Ask the patient to lean forward and listen again. Document that the pericarditis has resolved.
ask pt to lean forward
When a patient is taking an immunosuppressant following heart transplantation, the nurse would determine which of the following as the MOST important intervention? Educate the patient regarding signs and symptoms of infection. Assess vital signs every 4 hours. Prevent exposure to potentially harmful agents such as fresh fruit. Place the patient in an isolation room.
assess Vital signs every 4 hours
A client with chest pain arrives in the emergency department and receives nitroglycerin, morphine, oxygen, and aspirin. The health care provider diagnoses acute coronary syndrome. When the client arrives on the unit, vital signs are stable and the client does not report any pain. In addition to the medications already given, which medication does the nurse expect the health care provider to order? Carvedilol Nitroprusside Furosemide Digoxin
carvedilol
A nurse evaluates a client and suspects pericarditis. What indicator is considered the most characteristic symptom of pericarditis? Chest pain Fatigue Dyspnea Orthopnea
chest pain
A client is admitted to the hospital with possible acute pericarditis and pericardial effusion. The nurse knows to prepare the client for which diagnostic test to confirm the client's diagnosis? Computed tomography Echocardiography Chest x-ray Cardiac catheterization
echocardiography
A client is diagnosed with infective endocarditis. What laboratory values will the nurse assess? Select all that apply. decreased C-reactive protein elevated erythrocyte sedimentation rate (ESR) decreased erythrocyte sedimentation rate elevated white blood cell (WBC) count elevated C-reactive protein
elevated WBC elecated C reaction protein elevated ESR
A client reports headaches and "just not feeling right," which the client blames on ongoing sleep disturbances. Inspection reveals Janeway lesions on the bottoms of the client's feet. These symptoms may indicate: myocarditis. dilated cardiomyopathy. infective endocarditis. rheumatic fever.
infective endocarditis
The nurse is auscultating the heart of a client diagnosed with mitral valve prolapse. Which is often the first and only manifestation of mitral valve prolapse? Extra heart sound Syncope Fatigue Dizziness
extra heart sound
The nurse working in the medical intensive care unit is caring for a client admitted with mitral stenosis. What will the nurse assess is related to the pathophysiology of mitral stenosis? Select all that apply. fatigue history of endocarditis high-pitched murmur shortness of breath with activity low-pitched murmur
fatiguelow-pitched murmurshortness of breath with activityhistory of endocarditis
An 8-year-old child is admitted to a medical-surgical unit with a diagnosis of syndrome of inappropriate antidiuretic syndrome (SIADH). Drag words from the choices below to fill in each blank in the following sentence. The nurse will closely monitor the client's fluid balance, serum potassium, and level of consciousness. Laboratory Valuesblood glucoseserum sodium
fluid balance, potassium and LOC
The nurse is caring for a client diagnosed with infective endocarditis and awaiting blood culture results. The client asks, "Where did I pick up these bacteria?" The nurse is most safe to speculate which of the following? From ingestion of a food From a break in the skin From the fecal-oral route From droplets from a cough
from a break in the skin
The school nurse observes an 8th grader at school who suddenly is losing weight, is not participating in gym, and is in poor academic standing. The nurse takes a history and notes that the child seems very nervous. The nurse notifies the parent, who explains that the child has just been seen by the family health care provider and tested low for thyroid-stimulating hormone (TSH). For which condition will the nurse devise a plan of care? Graves disease Diabetes mellitus Hashimoto thyroid disease Hypothyroidism
graves diseaseb
A nurse is caring for a client with end-stage cardiomyopathy and the client's spouse asks the nurse to clarify one of the last treatment options available that the health care provider mentioned. What is considered to be one of the last treatments for end-stage cardiomyopathy? annuloplasty heart transplantation xenograft tissue valve valvuloplasty
heart transplantation
Which type of graft is used when a heart valve replacement is made of tissue from an animal heart valve? Allograft Heterograft Homograft Autograft
heterograft
The parents of a child with congenital adrenal hyperplasia bring the child to the emergency department for evaluation because the child has had persistent vomiting. What finding would lead the nurse to suspect that the child is experiencing an acute adrenal crisis? Hypernatremia Hypertension Hyperkalemia Bradycardia
hyperkalemia
A client's elevated cholesterol levels are being managed with atorvastatin daily. What is a common side effect the nurse will teach the client that will require monitoring? severe muscle pain hyperglycemia increased liver enzymes hyperuricemia
increased liver enzymes
The nurse is caring for a client who has been diagnosed with aortic stenosis. The client is prescribed digoxin. What is the rationale for the medication? dyspnea angina left ventricular dysfunction edema
left ventricular dysfunction
The nurse is teaching a client diagnosed with coronary artery disease about nitroglycerin. What is the cardiac premise behind administration of nitrates? More blood returns to the heart. Preload is reduced. It functions as a vasoconstrictor. It increases myocardial oxygen consumption.
preload is reduced
The nurse completes an assessment of a client admitted with pericarditis. What client symptom will the nurse correlate with the diagnosis of pericarditis? elevated ESR and CRP reports of constant chest pain fatigue lasting more than 1 month dyspnea SUBMIT ANSWER
reports of constant chest pain
While auscultating the heart of a pediatric client who is recovering from acute rheumatic fever, the nurse hears a murmur. This sound may indicate: atrial gallop. pericarditis. cardiac tamponade. valve damage.
valve damage
