A nurse is caring for an adolescent in an emergency department.

Vital Signs.

2300: Medical History.

Blood pressure 120/78 mm Hg. Apical pulse rate 100/min.

Respiratory rate 20/min.

2400: Temperature 37.9° C (100.2° F). Oxygen saturation 98% on room air.

Nurses' Notes.

Blood pressure 112/64 mm Hg. Apical pulse rate 108/min.

Respiratory rate 28/min.

Temperature 38.9° C (102° F). Oxygen saturation 95% on room air.

Medical History.

History of rheumatic fever with resulting cardiac valve damage.

Nurses' Notes.

2300: Adolescent brought to emergency department by their parent.

Adolescent reports intermittent low-grade fever and anorexia.

Manifestations presented a few days after having dental work performed.

Now they are worse.

Adolescent noticed shortness of breath with exertion today.

Adolescent in semi-reclining position.

Respirations easy and unlabored while at rest.

Mild dyspnea observed when adolescent ambulated to the room.

Lung sounds clear bilaterally.

Oral mucous membranes pink with petechiae noted.

Adolescent reports diffuse joint pain as 2 on a scale of 0 to 10. 2400: Adolescent restless and sweating, sitting in high-Fowler's position.

Dyspnea noted at rest.

Adolescent reports pain in mid-chest as dull, aching, and as 2 on a scale of 0 to 10. Few coarse rales auscultated bilaterally.

The nurse reports the 2400 assessment findings to the provider.

Which of the following should the nurse anticipate the provider will prescribe? For each potential provider's prescription, specify if the potential prescription is anticipated or contraindicated for the client.

Obtain blood cultures x 3.

Administer antibiotic therapy.

Obtain an echocardiogram.

Restrict dental hygiene.

Perform strenuous exercise regimen twice daily.

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale:

Obtaining blood cultures x 3 is anticipated for the client. This is because the adolescent’s symptoms such as fever, shortness of breath, and petechiae could indicate a bacterial infection, possibly endocarditis, which is a risk for individuals with a history of rheumatic fever and cardiac valve damage. Blood cultures would help identify the causative bacteria.

Choice B rationale:

Administering antibiotic therapy is anticipated for the client. The adolescent’s symptoms suggest a possible bacterial infection, which could have been introduced during the recent dental work. Antibiotics would help eliminate the bacteria and prevent further complications.

Choice C rationale:

Obtaining an echocardiogram is anticipated for the client. Given the adolescent’s history of rheumatic fever and cardiac valve damage, and current symptoms like shortness of breath and chest pain, an echocardiogram would help assess the condition of the heart valves and detect any abnormalities.

Choice D rationale:

Restricting dental hygiene is contraindicated for the client. Good oral hygiene is important, especially for individuals with a history of rheumatic fever and cardiac valve damage, as it helps prevent oral infections that could potentially spread to the heart.

Choice E rationale:

Performing a strenuous exercise regimen twice daily is contraindicated for the client. The adolescent is currently experiencing symptoms like shortness of breath and chest pain, which could be exacerbated by strenuous exercise. It’s important to avoid overexertion until the adolescent’s condition stabilizes.

So, the correct answer is, after analyzing all choices, Choices A, B, and C are anticipated for the client, while Choices D and E are contraindicated. .

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Correct Answer is ["B","E"]

Explanation

Choice A rationale:

Dependent rubor refers to redness of the skin that occurs when the leg is in a dependent (hanging down) position. It is often associated with peripheral artery disease. However, the child’s symptoms do not indicate this condition.

Choice B rationale:

Digitalis toxicity can occur as a result of high levels of the drug digoxin. Symptoms can include nausea, vomiting, weakness, and vision changes. Given that the child has been administered digoxin, there is a risk for this condition.

Choice C rationale:

Carditis is inflammation of the heart or its surroundings. It is usually caused by bacterial or viral infections. The child’s symptoms do not suggest an infection, making this choice less likely.

Choice D rationale:

Hypercyanotic spells, also known as “tet spells,” are associated with Tetralogy of Fallot, a specific congenital heart defect. The child has a history of congenital mitral stenosis, not Tetralogy of Fallot, making this choice less likely.

Choice E rationale:

Hypokalemia, or low potassium levels, can occur as a side effect of taking diuretics like furosemide. Given that the child has been administered furosemide, there is a risk for this condition.

Choice F rationale:

Fever is usually a response to infection or inflammation. The child’s symptoms do not suggest an infection or inflammation, making this choice less likely.

Choice G rationale:

Hypertension, or high blood pressure, is not indicated in the child’s symptoms or history. The child’s blood pressure readings are within normal range, making this choice less likely.

Choice H rationale:

A murmur is a sound that can be heard when listening to the heart with a stethoscope. It is often caused by turbulent blood flow through the heart. The child’s notes do not mention a murmur, making this choice less likely.

So, the correct answer is, the child is at risk for developing Digitalis toxicity and Hypokalemia. .

A. "Do you have a history of a heart attack?". B. "Have you had any recent immunizations?". C. "Do you have a family history of endocarditis?". D. "Have you had dental work done recently?".

Correct Answer is D

Explanation

Choice A rationale:

While a history of heart attack indicates a general risk for heart disease, it is not specifically associated with an increased risk for infective endocarditis.

Choice B rationale:

Immunizations do not typically increase the risk for infective endocarditis.

Choice C rationale:

Family history of endocarditis does not necessarily increase the risk for infective endocarditis.

Choice D rationale:

Dental work can introduce bacteria into the bloodstream, which can lead to infective endocarditis, especially in individuals with prosthetic heart valves.

So, the correct answer is D, after analyzing all choices.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","E"]

Explanation

The nurse obtains a health history from an older adult with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse helps identify a risk factor for IE?.

Correct Answer is D

Explanation

After receiving a change-of-shift report on four patients, which patient would the nurse assess first?.

A patient who has chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action would the nurse take first?.

Which patient statement would help the nurse confirm the previous diagnosis of chronic stable angina?.

The nurse is caring for a patient with mitral regurgitation. Where would the nurse listen to best hear a murmur typical of mitral regurgitation?.

Which statement by a patient with restrictive cardiomyopathy indicates that the nurse's discharge teaching about self-management has been effective?

In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective?.

Which data indicates to the nurse that the patient with stable angina is experiencing a side effect of metoprolol?.