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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Including fluoridated water in the toddler's diet is not a method of preventing iron deficiency anemia. Fluoride is beneficial for dental health, but it does not affect iron levels in the blood.

Choice B reason: Avoiding a diet that consists primarily of milk is a method of preventing iron deficiency anemia. Milk is low in iron and can interfere with iron absorption from other foods. It can also cause gastrointestinal bleeding in some children, leading to iron loss. The nurse should teach the parents to limit milk intake to no more than 24 ounces per day and offer iron-rich foods such as meat, eggs, beans, and green leafy vegetables.

Choice C reason: Administering fat-soluble vitamins daily is not a method of preventing iron deficiency anemia. Fat-soluble vitamins are vitamins A, D, E, and K, which are stored in the body and do not need to be taken daily. They do not affect iron levels in the blood.

Choice D reason: Limiting intake of high-protein foods is not a method of preventing iron deficiency anemia. High-protein foods are good sources of iron and can help prevent or treat iron deficiency an

A. Half-strength orange juice B. Half-strength infant formula C. Full-strength apple juice D. Full-strength chicken broth

Correct Answer is B

Explanation

Choice A reason: Half-strength orange juice is not a good choice for the infant, as it is acidic and may irritate the gastrointestinal tract. It also does not provide adequate calories or nutrition for the infant.

Choice B reason: Half-strength infant formula is a suitable choice for the infant, as it is bland and easy to digest. It also provides some calories and nutrition for the infant, who may have lost fluids and electrolytes due to the intussusception.

Choice C reason: Full-strength apple juice is not a good choice for the infant, as it is high in sugar and may cause diarrhea. It also does not provide adequate calories or nutrition for the infant.

Choice D reason: Full-strength chicken broth is not a good choice for the infant, as it is high in sodium and may cause dehydration. It also does not provide adequate calories or nutrition for the infant..

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching about iron deficiency anemia to the parents of a toddler. Which of the following should the nurse include as a method of preventing iron deficiency anemia?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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