The nurse is caring for an adult client who was diagnosed with a congenital heart defect as a child, which was later repaired with surgery. Which common complication of a heart defect should the nurse monitor that the client may still be at risk for?

Correct Answer: B

Rationale: Endocarditis is a common complication that individuals with repaired congenital heart defects may still be at risk for. Endocarditis is an infection of the inner lining of the heart chambers and valves. The altered structure of the heart tissue from the previous defect and surgery can create an increased risk for bacterial growth and infection. Patients with a history of congenital heart defects should be monitored for signs and symptoms of endocarditis, such as fever, fatigue, new heart murmurs, and evidence of systemic embolization. Prophylactic antibiotics before certain dental and surgical procedures may be recommended to prevent endocarditis in this population. Therefore, the nurse should be vigilant in monitoring for any symptoms suggestive of endocarditis in this client.

Correct Answer: B

Rationale: After a stroke, sensory-perceptual changes such as impaired proprioception, altered sensation, and decreased awareness of the affected side can increase the client's risk for injury. These changes can result in difficulties with balance, coordination, and spatial awareness, making the individual more prone to falls and accidents. It is important to implement safety measures and interventions to minimize the risk of injury in these clients, such as providing a structured environment, using assistive devices, and encouraging regular monitoring and assistance as needed.

Correct Answer: D

Rationale: Crepitation refers to a grating sound or sensation that occurs when there is rubbing together of the roughened articular surfaces of bones within a joint. It is commonly associated with conditions such as osteoarthritis or joint injury. Therefore, if the nurse hears a grating sound while assessing the range of motion of a patient's hip, the appropriate documentation of this finding would be crepitation.

Correct Answer: A

Rationale: The priority action for the nurse before initiating discharge teaching with a client with diabetes and a large wound is to assess the client's current knowledge regarding dressing changes. This step is crucial as it helps the nurse to understand the client's baseline understanding and skills related to wound care, which will guide the teaching process effectively. By asking the client to state what they know about the current dressing changes, the nurse can identify any knowledge gaps or misconceptions that need to be addressed. This assessment will ensure that the teaching is tailored to the client's specific needs and promotes successful wound healing and overall diabetes management.

Correct Answer: B

Rationale: In rheumatoid arthritis, the health history often includes systemic symptoms such as weight loss and fever. Rheumatoid arthritis is a chronic inflammatory autoimmune disease that affects multiple joints symmetrically. Unlike osteoarthritis where joint stiffness is often relieved by activity, stiffness in rheumatoid arthritis is typically worse in the morning and after inactivity. In rheumatoid arthritis, joint deformities can occur in various joints, not just limited to the hands. Heberden's nodes are characteristic of osteoarthritis, not rheumatoid arthritis.

Correct Answer: C

Rationale: The priority outcome for a client with deep vein thrombosis (DVT) receiving intravenous heparin is to prevent bleeding. Heparin is an anticoagulant medication used to prevent the formation of blood clots, but one of its potential side effects is bleeding due to its ability to prevent blood clotting. It is crucial to closely monitor the client for signs of bleeding while on heparin therapy, such as easy bruising, black or tarry stools, blood in the urine, or excessive bleeding from wounds. Preventing bleeding is essential to avoid complications associated with anticoagulant therapy.

Correct Answer: C

Rationale: A urine output of 200 mL in 8 hours is considered low, especially for a client with cardiomyopathy who is receiving diuretic therapy. This could indicate inadequate cardiac output or worsening heart failure. It is crucial for the nurse to notify the healthcare provider promptly so that appropriate interventions can be initiated to address the underlying cause and prevent further complications. Waiting for improvement without taking action could lead to deterioration in the client's condition.

Correct Answer: A

Rationale: In a patient with a newly created ileal diversion with a continent reservoir, demonstrating care for the collection device signifies that the patient has understood the importance of maintaining hygiene and proper management of the device. This behavior indicates that the teaching provided by the nurse has been effective in helping the patient take care of the diversion and prevent complications such as infection or skin irritation. Understanding how to care for the collection device is crucial for the patient's overall well-being and quality of life with the continent reservoir.

Correct Answer: B

Rationale: The brown pigmentation of the lower extremities in clients with venous stasis is primarily caused by the breakdown of red blood cells in the congested tissues. When there is venous stasis, the blood circulation is impaired, leading to a backup of blood in the lower extremities. This stagnant blood contains hemosiderin, a byproduct of red blood cell breakdown. Over time, the hemosiderin deposits in the tissues, causing the characteristic brown discoloration seen in conditions such as chronic venous insufficiency. This process is known as hemosiderin deposition and is a common consequence of venous stasis.