Share This Link

Malaise: Malaise is a common symptom of infective endocarditis, indicating generalized discomfort or fatigue. However, it is not an immediate life-threatening condition and does not require urgent intervention.

Fever: Fever is common in infective endocarditis due to the underlying infection. While important, it is expected and usually managed with antipyretics and antibiotics. It is not as urgent as dyspnea.

Anorexia: Anorexia is also a common symptom of infective endocarditis but is not an immediate threat to the client’s health.

Increase the client's oral fluid intake. While hydration is important for overall health, it will not directly address the cold feet caused by poor circulation in this scenario.

Place a moist heating pad under the client's feet. Heating pads, especially moist ones, can increase the risk of burns and should be avoided in clients with vascular occlusions, as they may have decreased sensation.

Rub the client's feet briskly for several minutes. Rubbing the feet briskly could cause skin breakdown and injury due to fragile skin and impaired circulation.

The stockings prevent varicose veins. Antiembolism stockings are not specifically used to prevent varicose veins. They are primarily used to prevent blood clots and improve circulation after surgery.

The stockings replace the need for postoperative leg exercises. Antiembolism stockings do not replace the need for leg exercises. Movement and exercise are still necessary to promote circulation and prevent DVT.

The stockings are used to reduce pain. Antiembolism stockings are not designed to reduce pain. Their main purpose is to prevent blood clots and improve circulation.

Soft, pliable calf muscle: A soft and pliable calf muscle is not indicative of a thrombus. Typically, a thrombus leads to swelling and firmness in the affected area.

Cool and clammy skin: Cool and clammy skin could indicate poor circulation, but it is not specific to a thrombus.

Temperature > 100°F: A fever could indicate an infection but is not a classic sign of a thrombus.

"It usually takes at least 2 to 3 days for heparin to dissolve a clot." Heparin does not dissolve clots; it prevents the formation of new clots and stops existing clots from growing.

"The time it takes for heparin to dissolve a clot depends on the size of the clot." This is incorrect because heparin does not dissolve clots, regardless of their size.

"The time it takes heparin to dissolve clots varies between clients." This is incorrect as well, as heparin does not dissolve clots at all.

S3 heart sound: An S3 heart sound is often associated with heart failure and volume overload, not specifically mitral stenosis.

Cyanosis: While cyanosis can occur in advanced stages of heart disease, it is not a primary symptom of mitral stenosis. It indicates severe oxygenation issues, which are usually late findings.

S4 heart sound: An S4 heart sound is typically associated with left ventricular hypertrophy, which can occur in advanced cases of mitral stenosis. However, it's not a specific early manifestation of the condition.

Tell the client to take another nitroglycerin tablet in 15 minutes. Nitroglycerin can be taken every 5 minutes, up to three doses, for chest pain. Waiting 15 minutes to take another dose is too long and can delay necessary treatment.

Advise the client to take an antacid. Antacids are not appropriate for managing chest pain that may be related to angina or a myocardial infarction. This response may delay critical treatment.

Advise the client to come into the office. This would delay care in a potential emergency situation. If the client is experiencing unrelieved chest pain after taking nitroglycerin, immediate emergency care is necessary.

Creatinine phosphokinase: Creatinine phosphokinase (CPK) typically returns to normal levels within 3 days after a myocardial infarction, so it would no longer be elevated at this point.

Myoglobin: Myoglobin rises early after a myocardial infarction but is not specific to heart muscle and returns to normal within 24 hours, so it would not be elevated at this time.

Creatinine kinase-MB: Creatinine kinase-MB (CK-MB) usually returns to normal levels within 2 to 3 days after a myocardial infarction, so it is unlikely to still be elevated 6 days later.

Nitroglycerin: Nitroglycerin is used to relieve chest pain by dilating coronary arteries and increasing blood flow. However, in the immediate setting of a suspected MI, oxygen is prioritized to ensure adequate oxygenation.

Aspirin: Aspirin is essential in the early treatment of MI to prevent further clot formation by inhibiting platelet aggregation, but oxygen would still come first if the client’s oxygenation is compromised.

Morphine: Morphine is used for pain relief and to reduce anxiety and oxygen demand on the heart. However, it is administered after ensuring oxygen supply.

Eggs: Eggs, particularly the yolks, are high in cholesterol and should be limited in a low-cholesterol diet.

Milk: Full-fat milk is high in saturated fat and cholesterol. If the client consumes milk, it should be low-fat or non-fat varieties.

Liver: Liver is high in cholesterol and should be avoided by clients following a low-cholesterol diet.