A nurse is assessing a client two months after mitral valve replacement. The client complains of malaise, anorexia, weight loss, chills, and fever. The nurse suspects the client may have endocarditis. What other assessment sign is associated with infectious endocarditis?
Muffled heart sounds
Palpitations
Hives
Splinter hemorrhages
The Correct Answer is D
A. Muffled heart sounds are associated with pericardial effusion or tamponade, not infective endocarditis.
B. Palpitations can occur but are not a classic sign of infective endocarditis.
C. Hives suggest an allergic reaction, not endocarditis.
D. Splinter hemorrhages (tiny, red-brown streaks under the nails) are a classic sign of infective endocarditis due to small emboli from the infected heart valves.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Elevated troponins are the most specific and sensitive markers for myocardial injury. Troponin I and Troponin T levels rise within a few hours of an AMI and remain elevated for days, confirming cardiac damage.
B. Elevated hemoglobin is not an indicator of cardiac injury. Hemoglobin levels are used to assess oxygen-carrying capacity and anemia.
C. Elevated B-type natriuretic peptide (BNP) is a marker for heart failure, not acute myocardial infarction.
D. Elevated creatine kinase (CK), particularly CK-MB, can indicate muscle injury, including cardiac injury, but it is less specific than troponins for diagnosing AMI.
Correct Answer is ["A","D","E"]
Explanation
A. Increased blood pressure is expected due to excess fluid in the vascular system, which raises blood volume and pressure.
B. Hematocrit is typically decreased in fluid volume overload due to hemodilution rather than increased.
C. Increased temperature is not a common finding in fluid overload, as fever is usually associated with infection rather than volume excess.
D. Increased heart rate (tachycardia) occurs as the heart compensates for excess fluid and decreased cardiac output.
E. Increased respiratory rate is common due to pulmonary congestion and fluid accumulation in the lungs, leading to dyspnea.
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