A nurse is assessing a client two months after mitral valve replacement. The client complains of malaise, anorexia, weight loss, chills, and fever. The nurse suspects the client may have endocarditis. What other assessment sign is associated with infectious endocarditis?
Muffled heart sounds
Palpitations
Hives
Splinter hemorrhages
The Correct Answer is D
A. Muffled heart sounds are associated with pericardial effusion or tamponade, not infective endocarditis.
B. Palpitations can occur but are not a classic sign of infective endocarditis.
C. Hives suggest an allergic reaction, not endocarditis.
D. Splinter hemorrhages (tiny, red-brown streaks under the nails) are a classic sign of infective endocarditis due to small emboli from the infected heart valves.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Complete heart block (third-degree AV block) is characterized by a complete dissociation between atrial and ventricular activity, with P waves and QRS complexes occurring independently of each other.
B. Sinus tachycardia presents with a regular rhythm, a heart rate above 100 beats per minute, and distinct P waves preceding each QRS complex.
C. Idioventricular rhythm occurs when the heart's primary pacemakers fail, leading to a slow ventricular rate (usually 20-40 bpm) with wide QRS complexes and no preceding P waves.
D. Ventricular tachycardia (VT) is a life-threatening arrhythmia characterized by a rapid ventricular rate (typically >100 bpm), wide QRS complexes, and an absence of P waves. VT can be sustained or non-sustained and may require immediate intervention if the patient is unstable.
Correct Answer is ["A","D","E"]
Explanation
A. Increased blood pressure is expected due to excess fluid in the vascular system, which raises blood volume and pressure.
B. Hematocrit is typically decreased in fluid volume overload due to hemodilution rather than increased.
C. Increased temperature is not a common finding in fluid overload, as fever is usually associated with infection rather than volume excess.
D. Increased heart rate (tachycardia) occurs as the heart compensates for excess fluid and decreased cardiac output.
E. Increased respiratory rate is common due to pulmonary congestion and fluid accumulation in the lungs, leading to dyspnea.
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