The nurse is conducting a physical assessment on a client with infective endocarditis (IE). The nurse observes flat, reddened, non-tender maculae on the hands and feet.

What does the nurse understand these to be?

Heberden’s nodes.

Bouchard’s nodes.

Janeway lesions.

Tophi.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Heberden’s nodes are bony swellings that occur at the distal interphalangeal finger joint, a sign of osteoarthritis. They are not associated with infective endocarditis (IE).
Choice B rationale
Bouchard’s nodes are similar to Heberden’s nodes but occur at the proximal interphalangeal finger joint. They are also a sign of osteoarthritis and not associated with IE.
Choice C rationale
Janeway lesions are flat, painless, red or purple spots on the palms of the hands or the soles of the feet. They are associated with IE and are caused by septic emboli which are small clots filled with bacteria. These emboli can lodge in small blood vessels, causing these characteristic lesions.
Choice D rationale
Tophi are hard, uric acid deposits under the skin. They are a sign of chronic gout, not IE.

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Correct Answer is A

Explanation

Choice A rationale
Skin hyperpigmentation is a common symptom of chronic venous insufficiency. This happens because blood pools in the veins and can leak into the surrounding tissue, causing a change in skin color.
Choice B rationale
Gangrene is not a typical symptom of chronic venous insufficiency. Gangrene is a serious condition that occurs when tissue dies due to a lack of blood flow.
Choice C rationale
Edema, or swelling, is a common symptom of chronic venous insufficiency, but it typically occurs in the lower legs and ankles, not above the knee.
Choice D rationale
Deep vein thrombus formation is not a typical symptom of chronic venous insufficiency. However, a history of deep vein thrombosis can increase the risk of developing chronic venous insufficiency.

A. Palpable liver edge 2 cm below the ribs on the right side. B. Serum potassium level of 3.0 mEq/L after 1 week of therapy. C. Weight increase from 120 pounds to 122 pounds over 3 days. D. Presence of 1+ to 2+ edema in the feet and ankles.

Correct Answer is B

Explanation

Choice A rationale
While palpating the liver edge can provide information about liver health and potential fluid accumulation, it is not typically a priority assessment for a patient taking Digoxin (Lanoxin), Furosemide (Lasix), and Captopril.
Choice B rationale
A serum potassium level of 3.0 mEq/L is low (hypokalemia). This is a critical finding because both Digoxin and Furosemide can cause hypokalemia. Hypokalemia increases the risk of digoxin toxicity, which can lead to serious cardiac arrhythmias.
Choice C rationale
While weight gain may indicate worsening heart failure, a gain of 2 pounds over 3 days is not typically considered significant. However, any sudden or unexplained weight gain should be reported to the healthcare provider.
Choice D rationale
Presence of 1+ to 2+ edema in the feet and ankles could indicate worsening heart failure, but it is not as immediately concerning as hypokalemia in a patient taking Digoxin and Furosemide.

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The nurse is conducting a physical assessment on a client with infective endocarditis (IE). The nurse observes flat, reddened, non-tender maculae on the hands and feet. What does the nurse understand these to be?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 52-year-old male is diagnosed with chronic venous insufficiency, presenting with pooling of blood in the veins of the lower extremities and edema. Which of the following is an expected assessment finding of this disorder?

Correct Answer is A

Explanation

A patient with heart failure has recently started taking Digoxin (Lanoxin), Furosemide (Lasix), and Captopril. Which finding by the home health nurse is a priority to communicate to the healthcare provider?

Correct Answer is B

Explanation

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The nurse is conducting a physical assessment on a client with infective endocarditis (IE). The nurse observes flat, reddened, non-tender maculae on the hands and feet.

What does the nurse understand these to be?