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: This test will confirm if your child had a recent streptococcal infection, as it measures the level of antibodies that the body produces against the streptolysin O enzyme, which is produced by some strains of streptococcal bacteria. A high ASO titer indicates a recent or current streptococcal infection, which can trigger rheumatic fever in some children.
Choice B reason: This test will not indicate if your child has rheumatic fever, as it does not measure the inflammation or damage to the heart, joints, or other organs that rheumatic fever can cause. Rheumatic fever is diagnosed based on the presence of two major or one major and two minor criteria, as well as evidence of a preceding streptococcal infection.
Choice C reason: This test will not indicate if your child has a therapeutic blood level of an aminoglycoside, as it does not measure the concentration of this type of antibiotic in the blood. Aminoglycosides are used to treat serious infections caused by gram-negative bacteria, and their blood levels need to be monitored to prevent toxicity and ensure efficacy.
Choice D reason: This test will not confirm if your child has immunity to streptococcal bacteria, as it does not measure the level of protective antibodies that can prevent future infections. ASO antibodies are not protective, but rather indicate a past or present exposure to streptococcal bacteria.
Correct Answer is D
Explanation
Choice A reason: Headaches are not a specific finding for rhabdomyosarcoma of the nasopharynx, as they can be caused by many other conditions. Headaches may occur if the tumor compresses the cranial nerves or the brain, but this is not a common manifestation.
Choice B reason: Bleeding is not a specific finding for rhabdomyosarcoma of the nasopharynx, as it can be caused by many other conditions. Bleeding may occur if the tumor erodes the blood vessels or the mucosa, but this is not a common manifestation.
Choice C reason: Tearing is not a specific finding for rhabdomyosarcoma of the nasopharynx, as it can be caused by many other conditions. Tearing may occur if the tumor affects the lacrimal duct or the eye, but this is not a common manifestation.
Choice D reason: Swelling is an expected finding for rhabdomyosarcoma of the nasopharynx, as it indicates the presence of a mass in the nasal cavity or the pharynx. Swelling may cause nasal obstruction, difficulty breathing, or facial asymmetry. Swelling may also be palpable or visible on imaging studies.
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