The nurse obtains a health history from a patient with a prosthetic mitral valve who has
symptoms of infective endocarditis. Which question by the nurse
... [Show More] is most appropriate?
a. "Do you have a history of a heart attack?"
b. "Have you any recent immunizations?"
c. "Have you been to the dentist lately?"
d. "Is there a family history of endocarditis?" - Answer-C
Rationale: Dental procedures place the patient with a prosthetic mitral valve at risk for
infectious endocarditis (IE). Myocardial infarction (MI), immunizations, and a family
history of endocarditis are not risk factors for IE.
The health care provider writes the following admitting orders for a patient with
suspected IE who has fever and chills: ceftriaxone (Rocephin) 1.0 g intravenous
piggyback (IVPB) q12hr, acetylsalicylic acid (ASA) for temperature above 102° F (38.9°
C), and blood cultures 2, complete blood cell count (CBC), and electrocardiogram
(ECG). When admitting the patient, the nurse gives the highest priority to
a. obtaining the blood cultures.
b. initiating the IV antibiotic.
c. scheduling the ECG.
d. administering the ASA. - Answer-A
Rationale: Treatment of the IE with antibiotics should be started as quickly as possible,
but it is essential to obtain blood cultures before initiating antibiotic therapy to obtain
accurate sensitivity results. The ECG and ASA should also be accomplished rapidly, but
the blood cultures (and then administration of the antibiotic) have highest priority.
During the assessment of a patient with IE, the nurse would expect to find
a. substernal chest pain and pressure.
b. splinter hemorrhages of the lips.
c. dyspnea and a dry, hacking cough.
d. a new regurgitant murmur. - Answer-D
Rationale: New regurgitant murmurs occur in IE because vegetation on the valves
prevents valve closure. Splinter hemorrhages occur on the nailbeds. Chest pain for
pressure is not typical for the patient with IE and would be more consistent with angina
or MI. Although dyspnea may occur as a result of heart failure, a moist cough would be
expected rather than a dry, hacking cough.
A patient hospitalized with IE develops sharp left flank pain and hematuria. The nurse
notifies the health care provider, recognizing that these symptoms may indicate
a. septicemia.
b. acute pyelonephritis.
c. vegetative embolization.
d. glomerulonephritis. - Answer-C
Rationale: The patient's clinical manifestations and history of IE indicate embolization.
Sudden onset flank pain is not typical of pyelonephritis, septicemia, or
glomerulonephritis.
Which of these assessment data obtained by the nurse when assessing a patient with
acute pericarditis should be reported immediately to the health care provider?
a. Blood pressure (BP) of 166/96
b. Jugular vein distension (JVD) to the level of the jaw
c. Pulsus paradoxus 8 mm Hg
d. Level 6/10 chest pain with deep inspiration - Answer-B
Rationale: The JVD indicates that the patient may have developed cardiac tamponade
and may need rapid intervention to maintain adequate cardiac output. Hypertension
would not be associated with complications of pericarditis, and the BP is not high
enough to indicate that there is any immediate need to call the health care provider. A
pulsus paradoxus of 8 mm Hg is normal. Level 6/10 chest pain should be treated but is
not unusual with pericarditis.
The nurse has identified a nursing diagnosis of acute pain related to inflammatory
process for a patient with acute pericarditis. The most appropriate intervention by the
nurse for this problem is to
a. force fluids to 3000 ml/day to decrease fever and inflammation.
b. teach the patient to take deep, slow respirations to control the pain.
c. position the patient in Fowler's position, leaning forward on the overbed table.
d. remind the patient to ask for the opioid pain medication every four hours. - Answer-C
Rationale: Sitting upright and leaning forward frequently will decrease the pain
associated with pericarditis. Forcing fluids will not decrease the inflammation or pain.
Taking deep respirations tends to increase pericardial pain. Opioids are not very
effective at controlling pain caused by acute inflammatory conditions and are usually
ordered PRN. The patient would receive scheduled doses of a nonsteroidal
antiinflammatory drug (NSAID).
During postoperative teaching with a patient who had a mitral valve replacement with a
mechanical valve, the nurse instructs the patient regarding
a. the need to avoid high-voltage electrical fields.
b. how to monitor anticoagulation therapy.
c. the need for valve replacement in 7 to 10 years.
d. how to check the radial pulse. - Answer-B
Rationale: Anticoagulation with warfarin (Coumadin) is needed for a patient with
mechanical valves to prevent clotting on the valve. There is no need to avoid highvoltage electrical fields. Mechanical valves are durable and would last longer than 7 to
10 years. Monitoring of radial pulse is not necessary after valve replacement.
Which information obtained by the nurse when assessing a patient admitted with mitral
valve stenosis should be communicated to the health care provider immediately?
a. The patient has a loud diastolic murmur all across the precordium.
b. The patient has crackles audible to the lung apices.
c. The patient has a palpable thrill felt over the left anterior chest.
d. The patient has 4+ peripheral edema in both legs. - Answer-B
Rationale: Crackles that are audible throughout the lungs indicate that the patient is
experiencing severe left ventricular failure and needs immediate interventions such as
diuretics. A diastolic murmur and palpable thrill would be expected in a patient with
mitral stenosis. Although 4+ peripheral edema indicates a need for a change in therapy,
it does not need to be addressed urgently.
A patient with percarditis reports increasing chest pain. The nurse further assesses the
patient's pain based on the knowledge that:
A. chest pain with pericarditis is expected, but increasing chest pain could indicate other
complications, such as a myocardial infacrtion
B. chest pain with pericarditis in an uncommon finding and needs to be further assessed
C. actually, assessing chest pain is not necessary
D. I can't come up with a third option so please pick one of the above - Answer-A. chest
pain with pericarditis is expected, but increasing chest pain could indicate other
complications, such as a myocardial infarction.
It is important to distinguish between these two types of chest pain, since the treatment
plans are different.
A patient with pericarditis reports increasing chest pain. The nurse further assess the
patient's pain. Which on the following manifestations leads the nurse to believe that the
patient is experiencing a myocardial infarction?
A. pain increases with deep breathing and lying flat
B. pain is relieved with sitting up and leaning forward
C. pain is described as crushing pressure, lasting more than 30 minutes
D. pleural fricition rub is heard upon ausculation - Answer-C. pain is described as
crushing pressure, lasting more than 30 minutes
The other answer choices are expected findings for a patient with pericarditis.
In planning community education for prevention of spinal cord injuries, the nurse targets
a. elderly men
b. teenage girls
c. elementary school-age children
d. adolescent and young adult men - Answer-D. adolescent and young adult men
Rationale: Spinnal cord injuries are highest in young adult men between the ages of 15
and 30 and those who are impulsive or risk takers in daily living. Other risk factors
include alcohol and drug abuse as well as participation in sports and occupational
exposure to trauma or violence.
An initial incomplete spinal cord injury often results in complete cord damage because
of
a. edematous compression of the cord above the level of the injury
b. continued trauma to the cord resulting from damage to stabilizing ligaments
c. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites
d. mechanical transection of the cord by sharp vertebral bone fragments after the initial
injury - Answer-c. infarction and necrosis of the cord caused by edema, hemorrhage,
and metabolites
Rationale: The primary injury of the spinal cord rarely affects the entire cord, but the
patho of secondary injury may result in damage that is the same as mechanical
severance of the cord. Complete cord dissolution occurs through autodestruction of the
cord by hemorrhage, edema, and the presence of metabolites and norepinephrine.
resulting in anoxia and infarction of the cord. Edema resulting from the inflammatory
response may increase the damage as it extends above and below the injury site.
A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient
based on the knowledge that
a. rehabilitation measures cannot be initiated until spinal shock has resolved
b. the patient will need continuous monitoring for hypotension, tachycardia, and
hypoxemia
c. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex
emptying of the bladder
d. the patient will have complete loss of motor and sensory functions below the level of
the injury, but autonomic functions are not affected - Answer-C. c. resolution of spinal
shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder
Rationale: Spinal shock occurs in about half of all people with acute spinal cord injury.
In spinal shock, the entire cord below the level of the lesion fails to function, resulting in
a flaccid paralysis and hypomotility of most processes without any reflex activity. Return
of reflex activity signals the end of spinal shock. Sympathetic function is impaired below
the level of the injury because sympathetic nerves leave the spinal cord at the thoracic
and lumbar areas, and cranial parasympathetic nerves predominate in control over
respirations, heart, and all vessels and organ below the injury. Neurogenic shock results
from loss of vascular tone caused by the injury and is manifested by hypotension,
peripheral vasodilation, and decreased CO. Rehab activities are not contraindicated
during spinal shock and should be instituted if the patient's cardiopulmonary status is
stable.
Two days following a spinal cord injury, a patient asks continually about the extent of
impairment that will result from the injury. The best response by the nurse is,
a. you will have more normal function when spinal shock resolves and the reflex arc
returns
b. the extent of your injury cannot be determined until the secondary injury to the cord is
resolved
c. when your condition is more stable, an MRI will be done that can reveal the extent of
the cord damage
d. because long-term rehabilitation can affect the return of tunction, it will be years
before we can tell when the complete effect will be
B. the extent of your injury cannot be determined until the secondary injury to the cord is
resolved - Answer-Rationale: Until the edema and necrosis at the site of the injury are
resolved in 72 hours to 1 week after the injury, it is not possible to determine how much
cord damage is present from the initial injury, how much secondary injury occurred, or
how much the cord was damaged by edema that extended above the level of the
original injury. The return of reflexes signals only the end of spinal shock, and the
reflexes may be inappropriate and excessive, causing spasms that complicate rehab.
A patient is admitted to the emergency department with a spinal cord injury at the level
of T2. Which of the following findings is of most concern to the nurse?
a. SpO2 of 92%
b. HR of 42 beats/min
c. BP of 88/60
d. loss of motor and sensory function in arms and legs - Answer-b. HR of 42 beats/min
Rationale: Neurogenic shock associated with cord injuries above the level of T6 greatly
decrease the effect of the sympathetic nervous system, and bradycardia and
hypotension occur. A heart rate of 42 is not adequate to meet oxygen needs of the
body, and while low, the BP is not at a critical point. The O2 sat is ok, and the motor and
sensory loss are expected.
A patient is admitted to the emergency department with a possible cervical spinal cord
injury following an automobile crash. During the admission of the patient, the nurse
places the highest priority on
a. maintaining a patent airway
b. assessing the patient for head and other injuries
c. maintaining immobilization of the cervical spine
d. assessing the patient's motor and sensory function - Answer-a. maintaining a patent
airway
Rationale: The need for a patent airway is the first priority for any injured patient, and a
high cervical injury may decrease the gag reflex and ability to maintain an airway, as
well as the ability to breathe. Maintaining cervical stability is then a consideration, along
with assessing for other injuries and the patients neuro status.
Without surgical stabilization, immobilization and traction of the patient with a cervical
spinal cord injury most frequently requires the use of
a. kinetic beds
b. hard cervical collars
c. skeletal traction with skull tongs
d. sternal-occipital-mandibular immobilizer (SOMI) brace - Answer-C. skeletal traction
with skull tongs
Rationale: Cervical injuries usually require skeletal traction with the use of Crutchfield,
Vinke, or other types of skull tongs to immobilize the cervical vertebrae, even if fracture
has not occurred. Hard cervical collars are used for minor injuries or for stabilization
during emergency transport of the patient. Sandbags are also used temporarily to
stabilize the neck during insertion of tongs or during diagnostic testing immediately
following the injury. Special turning or kinetic beds may be used to turn and mobilize
patients who are in cervcal traction.
During assessment of a patient with a spinal cord injury, the nurse determines that the
patient has a poor cough with diaphragmatic breathing. Based on this finding, the
nurses' first action should be to
a. initiate frequent turning and repositioning
b. use tracheal suctioning to remove secretions
c. assess lung sounds and respiratory rate and depth
d. prepare the patient for endotracheal intubation and mechanical ventilation - AnswerC. assess lungs sounds and respiratory rate and depth
Rationale: Because pneumonia and atelectasis are potential problems RT ineffective
coughing function, the nurse should assess the patient's breath sound and resp function
to determine whether secretions are being retained or whether there is progression of
resp impairment. Suctioning is not indicated unless lung sounds indicate retained
secretions: position changes will help mobilize secretions. Intubation and mechanical
ventilation are used if the patient becomes exhausted from labored breathing or if ABGs
deteriorate
A week following a spinal cord injury at T2, a patient experiences movement in his leg
and tells the nurse he is recovering some function. The nurses' best response to the
patient is,
a. it is really still too soon to know if you will have a return of function
b. the could be a really positive finding. can you show me the movement
c. that's wonderful. we will start exercising your legs more frequently now
d. im sorry, but the movement is only a reflex and does not indicate normal function -
Answer-B. the could be a really positive finding. can you show me the movement
Rationale: in 1 week following a spinal cord injury, there may be a resolution of the
edema of the injury and an end to spinal shock. When spinal shock ends, reflex
movement and spasms will occur, which may be mistaken for return of function, but with
the resolution of edema, some normal function may also occur. it is important when
movement occurs to determine whether the movement is voluntary and can be
consciously controlled, which would indicate some return of function.
During the patient's process of grieving for the losses resulting from spinal cord injury,
the nurse.... [Show Less]