A nurse on a cardiac care unit is caring for a preschooler who has a history of congenital mitral stenosis. Which of the following statements indicates that the client is at risk for developing rheumatic carditis?
The client has a nonproductive cough and wheezes in the lower lobes.
The client has dyspnea with a respiratory rate of 30/min and oxygen at 2 L/min via nasal cannula.
The client has a peripheral saline lock intact to the right forearm with no signs and symptoms of infection.
The client has lower extremity edema and decreased skin pigmentation noted to bilateral lower extremities.
The Correct Answer is D
Choice A reason: This statement does not indicate a risk for rheumatic carditis, but rather a possible respiratory infection or asthma. Rheumatic carditis is an inflammatory condition of the heart valves that can result from untreated streptococcal pharyngitis.
Choice B reason: This statement does not indicate a risk for rheumatic carditis, but rather a sign of heart failure. Dyspnea, tachypnea, and hypoxia are common manifestations of heart failure in children with congenital heart defects.
Choice C reason: This statement does not indicate a risk for rheumatic carditis, but rather a normal finding for a client who has an IV access. A peripheral saline lock is used to administer fluids and medications as needed, and it should be monitored for signs of infection, infiltration, or phlebitis.
Choice D reason: This statement indicates a risk for rheumatic carditis, as lower extremity edema and decreased skin pigmentation are signs of erythema marginatum, a characteristic rash that occurs in some cases of rheumatic fever. Erythema marginatum is a pink or red rash that spreads from the trunk to the extremities, and it may fade and reappear with changes in temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Intravenous immunoglobulin (IVIG) is the main treatment for Kawasaki disease, as it reduces the inflammation of the blood vessels and the risk of coronary artery aneurysms. IVIG is given as a single infusion over 10 to 12 hours, within the first 10 days of the onset of fever.
Choice B reason: Aspirin is also used to treat Kawasaki disease, as it reduces the fever, pain, and inflammation. However, it is not the first-line treatment, and it is given after IVIG to prevent thrombosis and platelet aggregation. Aspirin is given at a high dose during the acute phase, and then at a low dose until the inflammation subsides.
Choice C reason: Penicillin is not indicated for Kawasaki disease, as it is an antibiotic that treats bacterial infections. Kawasaki disease is not caused by bacteria, but by an unknown trigger that activates the immune system and causes systemic vasculitis.
Choice D reason: Acetaminophen is not effective for Kawasaki disease, as it does not reduce the inflammation or the risk of complications. Acetaminophen may be used to treat mild pain or fever, but it is not the main treatment. Moreover, acetaminophen may mask the fever and delay the diagnosis of Kawasaki disease.
Correct Answer is A
Explanation
Choice A reason: Elbow restraints are commonly used for infants who have undergone cleft lip and palate repair to prevent them from touching or rubbing their incisions, which could cause bleeding, infection, or disruption of the sutures¹².
Choice B reason: Wrist restraints are not appropriate for infants who have undergone cleft lip and palate repair because they do not prevent the infant from reaching their mouth with their fingers or objects. Wrist restraints are more suitable for older children or adults who need to avoid pulling out tubes or catheters³.
Choice C reason: Jacket restraints are not indicated for infants who have undergone cleft lip and palate repair because they do not restrict the movement of the arms or hands. Jacket restraints are more useful for children who need to be secured to a bed or chair to prevent falls or injuries³.
Choice D reason: Mummy restraints are not recommended for infants who have undergone cleft lip and palate repair because they immobilize the entire body and can cause respiratory distress, overheating, or skin breakdown. Mummy restraints are only used for short procedures that require minimal movement, such as venipuncture or lumbar puncture³.
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