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 D
Explanation
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.
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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