A nurse on a cardiac care unit is caring for a preschooler who has a history of congenital mitral stenosis. Which of the following statements indicates that the client is at risk for developing rheumatic carditis?

The client has a nonproductive cough and wheezes in the lower lobes.

The client has dyspnea with a respiratory rate of 30/min and oxygen at 2 L/min via nasal cannula.

The client has a peripheral saline lock intact to the right forearm with no signs and symptoms of infection.

The client has lower extremity edema and decreased skin pigmentation noted to bilateral lower extremities.

Answer and Explanation

The Correct Answer is D

Choice A reason: This statement does not indicate a risk for rheumatic carditis, but rather a possible respiratory infection or asthma. Rheumatic carditis is an inflammatory condition of the heart valves that can result from untreated streptococcal pharyngitis.

Choice B reason: This statement does not indicate a risk for rheumatic carditis, but rather a sign of heart failure. Dyspnea, tachypnea, and hypoxia are common manifestations of heart failure in children with congenital heart defects.

Choice C reason: This statement does not indicate a risk for rheumatic carditis, but rather a normal finding for a client who has an IV access. A peripheral saline lock is used to administer fluids and medications as needed, and it should be monitored for signs of infection, infiltration, or phlebitis.

Choice D reason: This statement indicates a risk for rheumatic carditis, as lower extremity edema and decreased skin pigmentation are signs of erythema marginatum, a characteristic rash that occurs in some cases of rheumatic fever. Erythema marginatum is a pink or red rash that spreads from the trunk to the extremities, and it may fade and reappear with changes in temperature.

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Correct Answer is ["B","C"]

Explanation

Choice A reason: Retinopathy is not a potential issue for a child who has leukemia, as it is a condition that affects the blood vessels of the retina, which can be caused by diabetes, hypertension, or sickle cell disease. Leukemia does not affect the retina, but it can cause blurred vision, eye pain, or headaches due to increased intracranial pressure or cranial nerve involvement.

Choice B reason: Hemorrhage is a potential issue for a child who has leukemia, as it is a condition that causes excessive bleeding, which can be caused by thrombocytopenia, coagulopathy, or bone marrow suppression. Leukemia can cause a low platelet count, which impairs the blood clotting process and increases the risk of bleeding from minor injuries, mucous membranes, or internal organs.

Choice C reason: Neuropathy is a potential issue for a child who has leukemia, as it is a condition that affects the nerves, which can be caused by chemotherapy, radiation, infection, or compression. Leukemia can cause nerve damage, which can result in numbness, tingling, pain, or weakness in the extremities, face, or trunk.

Choice D reason: Rheumatoid arthritis is not a potential issue for a child who has leukemia, as it is a condition that affects the joints, which can be caused by an autoimmune disorder, inflammation, or infection. Leukemia does not affect the joints, but it can cause bone pain, swelling, or fractures due to bone marrow infiltration or osteoporosis.

A. I will apply heat. B. I will have my child rest. C. I will compress the site. D. I will elevate the affected part.

Correct Answer is A

Explanation

Choice A reason: Applying heat to a bleeding site is not recommended for a child who has hemophilia, as it can increase blood flow and worsen the bleeding. The nurse should teach the parent to apply cold compresses instead.

Choice B reason: Having the child rest is a correct action, as it can reduce the movement of the affected part and prevent further injury or bleeding.

Choice C reason: Compressing the site is a correct action, as it can help stop the bleeding and form a clot. The nurse should teach the parent to apply firm and direct pressure to the site with a clean cloth or bandage.

Choice D reason: Elevating the affected part is a correct action, as it can reduce the swelling and pain caused by the bleeding. The nurse should teach the parent to elevate the part above the level of the heart.

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A nurse on a cardiac care unit is caring for a preschooler who has a history of congenital mitral stenosis. Which of the following statements indicates that the client is at risk for developing rheumatic carditis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a preschooler who has leukemia. After reviewing the child's information, which of the following potential issues should the nurse identify that the child is at risk for developing? (Select all that apply.)

Correct Answer is ["B","C"]

Explanation

A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicates a need for further teaching?

Correct Answer is A

Explanation

A nurse on a cardiac care unit is caring for a preschooler who has a history of congenital mitral stenosis. Which of the following statements indicates that the client is at risk for developing rheumatic carditis?

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