The client is diagnosed with pericarditis. Which are the most common
signs/symptoms the nurse would expect to find when assessing the client?
1. Pulsus paradoxus.
2. Complaints of fatigue and arthralgias.
3. Petechiae and splinter hemorrhages.
4. Increased chest pain with inspiration.4. Increased chest pain with inspiration.
4. Chest pain is the most common symptom of pericarditis, usually has an abrupt onset, and is aggravated by respiratory movements ( deep inspiration, coughing), changes in body position and swallowing.
The client is diagnosed with acute pericarditis. Which sign/symptom
warrants immediate attention by the nurse?
1. Muffled heart sounds.
2. Nondistended jugular veins.
Bounding peripheral pulses.
4. Pericardial friction rub.
1. Acute pericardial effusion interferes with normal cardiac filling and pumping causing venous congestion and decreased cardiac output. Muffled heart sounds indicative of acute pericarditis, must be reported to HCP.
The client is admitted to the medical unit to rule out carditis.
Which question should the nurse ask the client during the admission
interview to support this diagnosis?
1. "Have you had a sore throat in the last month?"
2. "Did you have rheumatic fever as a child?"
3. "Do you have a family history of carditis?"
4. "What over-the-counter (OTC) medication do you take?"
2. Rheumatic fever a systemic inflammatory disease caused by an abnormal immune response to pharyngeal infection by a group A beta-hemolytic streptococci causes carditis in about 50% of people who develop it
The client with pericarditis is prescribed an NSAID. Which teaching
instruction should the nurse discuss with the client?
1. Explain the importance of tapering off the medication.
2. Discuss that the medication will make the client drowsy.
3. Instruct the client to take the medication with food.
4. Tell the client to take the medication when the pain level is around "8."
3. NSAIDS must be taken with food, milk, or antacids to help decrease gastric distress. NSAIDs reduce inflammation, fever, and pericardial pain.
The client diagnosed with pericarditis is complaining of increased
pain. Which intervention should the nurse implement first?
1. Administer oxygen via nasal cannula.
2. Evaluate the client's urinary output.
3. Assess the client for cardiac complications.
4. Encourage the client to use the incentive spirometer.
3. The nurse must assess the client to determine if the pain is expected secondary to pericarditis or if the pain is indicative of a complication that requires intervention from the HCP.
The client diagnosed with pericarditis is experiencing cardiac
tamponade. Which collaborative intervention should the nurse
anticipate for this client?
1. Prepare for a pericardiocentesis.
2. Request STAT cardiac enzymes.
3. Perform a 12-lead electrocardiogram.
4. Assess the client's heart and lung sounds.
1. A pericardiocentesis removes fluid fro the pericardial sac and is the emergency treatment for cardiac tamponade.
The female client is diagnosed with rheumatic fever and prescribed
penicillin, an antibiotic. Which statement indicates the client needs
more teaching concerning the discharge teaching?
1. "I must take all the prescribed antibiotics."
2. "I may get a vaginal yeast infection with penicillin."
3. "I will have no problems as long as I take my medication."
4. "My throat culture was positive for a streptococcal infection."
3. Even with antibiotic treatment for rheumatic fever, the client may experience bacterial endocarditis in later years and should know this may occur.
Which potential complication should the nurse assess for in the
client with infective endocarditis who has embolization of vegetative
lesions from the mitral valve?
1. Pulmonary embolus.
2. Cerebrovascular accident.
4. Deep vein thrombosis.
2. Bacteria enter the bloodstream from invasive procedures and sterile platelet-fibrin vegetation forms on heart valves. The mitral valve is on the left side of the heart and, if the vegetation breaks off, it will go through the left ventricle into the systemic circulation and may lodge in the brain, kidneys or peripheral tissues.
Which nursing diagnosis would be priority for the client diagnosed
1. Anxiety related to possible long-term complications.
2. High risk for injury related to antibiotic therapy.
3. Increased cardiac output related to valve regurgitation.
4. Activity intolerance related to impaired cardiac muscle function.
4. Activity intolerance is a priority for the client with myocarditis, an inflammation of the heart muscle. nursing care is aimed at decreasing myocardial work and maintaining cardiac output.
The client with pericarditis is being discharged home. Which
intervention should the nurse include in the discharge teaching?
1. Be sure to allow for uninterrupted rest and sleep.
2. Refer client to outpatient occupational therapy.
3. Maintain oxygen via nasal cannula at two L/min.
4. Discuss upcoming valve replacement surgery.
1. Uninterrupted rest and sleep help decrease the workload of the heart and help ensure the restoration of physical and emotional health.
The client has just had a pericardiocentesis. Which interventions
should the nurse implement? Select all that apply.
1. Monitor vital signs every 15 minutes for the first hour.
2. Assess the client's heart and lung sounds.
3. Record the amount of fluid removed as output.
4. Evaluate the client's cardiac rhythm.
5. Keep the client in the supine position.
1. The nurse should monitor VS for any client who just undergone surgery
2. A pericardiocentesis involves entering the pericardial sac. Asessing heart and lung sounds allows assessment for cardiac failure
3. The pericardial fluid is documented as output
4. Evaulating the client's cardiac rhythm allows the nurse to assess for cardiac failure, whichis a complication of pericardiocentesis
The client with infective endocarditis is admitted to the medical
department. Which health-care provider's order should be implemented first?
1. Administer intravenous antibiotics.
2. Obtain blood cultures times two.
3. Schedule an echocardiogram.
4. Encourage bedrest with bathroom privileges.
2. Blood cultures must be done before administering antibiotics so that an adequate number of organisms can be obtained to culture and identify.