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 D

Explanation

Choice A reason: Blood pressure is not the most reliable indicator of fluid loss, as it can be affected by many other factors, such as cardiac output, vascular resistance, and blood volume. Blood pressure may not change significantly until the fluid loss is severe and the compensatory mechanisms are overwhelmed.

Choice B reason: Respiratory rate is not the most reliable indicator of fluid loss, as it can be affected by many other factors, such as oxygen demand, carbon dioxide levels, acid-base balance, and respiratory infections. Respiratory rate may increase as a result of fluid loss, but it is not a specific or sensitive sign.

Choice C reason: Skin integrity is not the most reliable indicator of fluid loss, as it can be affected by many other factors, such as age, nutrition, hydration, and skin diseases. Skin integrity may deteriorate as a result of fluid loss, but it is not a quantitative or objective measure.

Choice D reason: Body weight is the most reliable indicator of fluid loss, as it reflects the changes in the total body water and electrolytes. Body weight can be measured easily and accurately, and it can be compared with the previous or baseline values. A loss of more than 5% of the body weight indicates moderate dehydration, and a loss of more than 10% indicates severe dehydration.

A. Increased appetite B. Negative Babinski reflex C. Tachycardia D. Hyporeflexia

Correct Answer is D

Explanation

Choice A reason: Increased appetite is not a common finding in children with brain tumors. On the contrary, they may have decreased appetite, nausea, vomiting, or weight loss due to increased intracranial pressure or tumor location.

Choice B reason: Negative Babinski reflex is a normal finding in children over 2 years old and adults. It means that the toes curl downward when the sole of the foot is stimulated. A positive Babinski reflex, which means that the big toe moves upward and the other toes fan outward, is a sign of damage to the corticospinal tract, which may be caused by a brain tumor.

Choice C reason: Tachycardia, or rapid heart rate, is not a specific finding for brain tumors. It may be caused by many factors, such as fever, pain, anxiety, dehydration, or medications. However, some brain tumors may affect the autonomic nervous system, which regulates the heart rate, and cause bradycardia, or slow heart rate.

Choice D reason: Hyporeflexia, or diminished reflexes, is a possible finding in children with brain tumors. It indicates a dysfunction of the lower motor neurons, which may be affected by the tumor or the increased intracranial pressure. Hyporeflexia may manifest as weakness, numbness, or decreased muscle tone in the affected limbs.

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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?

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