ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 23 : Caring for Clients With Infectious and Inflammatory Disorders of the Heart
and Blood Vessels Questions
Question 1 of 5
The nurse is documenting assessment findings as a client is being admitted to a medical unit. Which of the following conditions, present with a diagnosis of infectious endocarditis, is correct to be documented as petechiae?
Correct Answer: D
Rationale: Petechiae is documented when tiny, pinpoint, reddish hemorrhagic spots on the skin and mucous membranes are noted. Purplish, painful nodules are Osler nodes. Black longitudinal lines in the nails are splinter hemorrhages. White areas in the retina surrounded by areas of hemorrhage are Roth's spots.
Question 2 of 5
The nurse is working on a telemetry unit at a local hospital. The nurse obtains report on a client with symptoms of sharp chest pain and tachycardia. The nurse begins to collect and critically think through assessment data. Which client symptom distinguishes between a myocardial infarction and myocarditis?
Correct Answer: D
Rationale: Clients may complain of sharp, stabbing discomfort that resembles a myocardial infarction; however, sitting up relieves the pain. There is no correlation between white frothy sputum, peripheral edema, or a pulse deficit and the disease processes.
Question 3 of 5
The nurse is caring for a client newly diagnosed with myocarditis. Which diagnostic test would the nurse find most helpful in confirming the diagnosis?
Correct Answer: C
Rationale: When choosing a definitive diagnostic test for myocarditis, a myocardial biopsy is most helpful. All of the other diagnostic tests provide information about the heart but is not as definitive as actually testing the heart muscle.
Question 4 of 5
Which common assessment question does the nurse use when admitting all clients that helps to screen for cardiomyopathy?
Correct Answer: B
Rationale: Having a family history of early cardiac deaths can indicate cardiomyopathy. Many individuals with cardiomyopathy are asymptomatic with the disorder not discovered until the affected person becomes acutely ill or dies.
Question 5 of 5
The nurse is caring for a five-client assignment on a cardiac unit. In caring for which client would the nurse be most correct to assess for an effusion?
Correct Answer: B
Rationale: An effusion, which is the accumulation of fluid between two layers of tissue, commonly occurs with pericarditis, which is the inflammation of the pericardium. Common causes of pericarditis include endocarditis, myocarditis, chest trauma, post heart surgery, or a myocardial infarction. Clients with chest pain, aortic stenosis, and mitral valve prolapse have conditions without current inflammation.