The nurse providing discharge teaching to a client admitted with pericarditis. The nurse informs the client that pericarditis can lead to:
Scarring of the mitral valve
Deformity of the valve leaflets
Inflammation of the endocardium
Pericardial effusion
The Correct Answer is D
A. Scarring of the mitral valve is typically associated with rheumatic heart disease, not pericarditis.
B. Deformity of the valve leaflets is seen in valvular heart diseases, not pericarditis.
C. Inflammation of the endocardium refers to endocarditis, a different condition from pericarditis.
D. Pericardial effusion, the accumulation of fluid in the pericardial sac, is a common complication of pericarditis and can lead to cardiac tamponade if not managed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Sinus bradycardia is characterized by a heart rate less than 60 beats/min, but in this case the rate is exactly 60, which is normal lower limit.
B. First degree heart block involves a prolonged PR interval (>0.20 seconds); here, the PR interval is normal (0.16 seconds).
C. Normal sinus rhythm has regular P waves and QRS complexes, a normal PR interval (0.12–0.20 seconds), and a heart rate between 60–100 beats/min.
D. Sick sinus syndrome is characterized by irregular rhythms and abnormal sinus node function, which is not indicated here.
Correct Answer is []
Explanation
Potential Condition: Atrial Fibrillation
The client presents with an irregular, tachycardic rhythm with unclear P waves, which are classic signs of atrial fibrillation (AF). Symptoms such as palpitations, dizziness, and shortness of breath are common with AF, particularly with a rapid ventricular response.
Actions to Take
• Administer an anticoagulant: AF increases the risk of thrombus formation in the atria, which can lead to embolic stroke. Anticoagulation reduces this risk, especially in symptomatic or persistent cases.
• Obtain a 12-lead ECG: This helps confirm the diagnosis, assess the rhythm in detail, and rule out other arrhythmias or ischemic changes that may be present.
Parameters to Monitor
• Manifestations of stroke: Clients with AF are at increased risk for embolic stroke. Neurological status should be closely monitored for signs of confusion, facial droop, weakness, or speech changes.
• PTT/INR: These lab values help assess coagulation status, particularly when anticoagulants such as warfarin or heparin are initiated, to ensure therapeutic levels and avoid bleeding complications.
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