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 reviewing the lab work of a client diagnosed with infective endocarditis. Which diagnostic study confirms the diagnosis?
Correct Answer: B
Rationale: A positive blood culture identifies the microorganism circulating in the blood. Slight leukocytosis is common but can be associated with other disease processes. Serum cardiac antigens and immunosuppressant assay are not typical diagnostic studies.
Question 2 of 5
The nurse is caring for a client diagnosed with infective endocarditis and awaiting blood culture results. The client asks, 'Where did I pick up these bacteria?' The nurse is most safe to speculate which of the following?
Correct Answer: D
Rationale: The microorganisms that cause infective endocarditis include bacteria and fungi. Streptococci and staphylococci are the bacteria most frequently responsible for this disorder. Both bacteria are abundantly found on the skin. These organisms are not found in the other locations.
Question 3 of 5
The nurse is planning care for a client with history of rheumatic carditis. Which nursing intervention would be most helpful in preventing further complications?
Correct Answer: B
Rationale: A nurse considers that clients with a history of rheumatic carditis may be at risk for further complications. Considering care (clean or sterile) during invasive procedures reduces the portals of entry for causative microorganisms. This is most helpful in preventing further complications. All other options are appropriate interventions when considering standards of care.
Question 4 of 5
The nurse is caring for a client with cardiac compromise related to mitral valve impairment. Which outcome of the eroding of the mitral valve is most significant?
Correct Answer: B
Rationale: The most significant outcome of the eroding of the mitral valve is heart failure. Blood leaking between the heart chambers diminishes the hearts ability to circulate blood efficiently. Eventually, the heart cannot keep up with the body's metabolic need, and heart failure occurs.
Question 5 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.