A nurse is caring for a patient diagnosed with infectious endocarditis. The nurse is aware that which of the following are potential assessment findings? (SELECT ALL THAT APPLY)
Osler Nodes
Splinter Hemorrhages
Petechial Hemorrhaging
Janeway Lesions
Fever with Chills
Correct Answer : A,B,C,D,E
A. Osler Nodes – These are tender, painful nodules on the fingers and toes, a classic sign of infective endocarditis.
B. Splinter Hemorrhages – Tiny blood clots under the fingernails occur due to microembolization from infected heart valves.
C. Petechial Hemorrhaging – Small red or purple spots on the skin or mucous membranes occur due to embolization of infected material.
D. Janeway Lesions – Painless, flat, red spots on the palms and soles caused by microemboli.
E. Fever with Chills – A common systemic symptom due to infection and inflammation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hypernatremia is incorrect. Furosemide can cause hyponatremia rather than hypernatremia due to increased sodium excretion.
B. Hypocalcemia is incorrect. While loop diuretics can cause some calcium loss, hypocalcemia is less common than hypokalemia.
C. Hypokalemia is correct. Furosemide is a loop diuretic that increases potassium excretion, leading to a risk of hypokalemia, which can cause muscle weakness, arrhythmias, and other complications.
D. Hyperkalemia is incorrect. Furosemide promotes potassium excretion, making hyperkalemia unlikely.
Correct Answer is ["B","C","D","E","F"]
Explanation
A. Increased appetite is not a symptom of worsening right-sided heart failure; clients may actually experience nausea or anorexia due to fluid congestion in the gastrointestinal system.
B. Distended neck veins (jugular venous distension) indicate increased venous pressure and systemic congestion, which are signs of worsening right-sided heart failure.
C. Worsening lower extremity edema occurs due to fluid retention and poor venous return, which are hallmark signs of right-sided heart failure.
D. Feeling fatigued is common as the heart struggles to pump blood effectively, leading to decreased oxygen delivery to tissues.
E. Unable to lie flat (orthopnea) is typically associated with left-sided heart failure but can also occur in right-sided failure due to fluid overload and pulmonary congestion.
F. Weight gain >2 lb in 24 hours suggests significant fluid retention and worsening heart failure, requiring prompt medical attention.
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