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 C

Explanation

Choice A reason: Tracheoesophageal fistula is a congenital anomaly that results from an abnormal connection between the trachea and the esophagus. It causes respiratory distress, choking, coughing, and cyanosis during feeding, and increased risk of aspiration pneumonia.

Choice B reason: Inguinal hernia is a protrusion of abdominal organs through the inguinal canal into the scrotum or labia. It causes a bulge in the groin area that may increase in size with crying or straining. It may also cause pain, vomiting, and impaired blood flow to the herniated tissue.

Choice C reason: Intussusception is a telescoping of one segment of the bowel into another, causing obstruction and impaired blood supply. It causes a palpable mass in the upper right quadrant, stools mixed with blood and mucus (resembling currant jelly), abdominal pain, vomiting, and shock.

Choice D reason: Hypertrophic pyloric stenosis is a narrowing of the pyloric sphincter due to hypertrophy of the surrounding muscle. It causes projectile vomiting, dehydration, weight loss, and a palpable olive-shaped mass in the upper right quadrant.

A. Water B. Oral rehydration solution C. Diluted apple juice D. Milk

Correct Answer is B

Explanation

Choice A reason: Water is not the best choice for a child who has acute gastroenteritis, as it does not contain the electrolytes and glucose that are lost through vomiting and diarrhea. Water alone can also dilute the blood sodium level and cause hyponatremia.

Choice B reason: Oral rehydration solution is the best choice for a child who has acute gastroenteritis, as it contains the optimal balance of electrolytes and glucose to prevent dehydration and electrolyte imbalance. It also helps to restore the intestinal function and prevent acidosis.

Choice C reason: Diluted apple juice is not the best choice for a child who has acute gastroenteritis, as it contains too much sugar and not enough sodium. This can worsen the diarrhea and cause hyperglycemia and hyperosmolar dehydration.

Choice D reason: Milk is not the best choice for a child who has acute gastroenteritis, as it can aggravate the intestinal inflammation and cause lactose intolerance. Milk can also increase the risk of bacterial infection and septicemia.

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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

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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