The nurse is assessing a child with suspected infective endocarditis. Which assessment finding would the nurse interpret as a sign of extracardiac emboli?
A) Pruritus
B) Roth spots
C) Delayed capillary refill
D) Erythema marginatum
Ans: B
Roth spots are splinter hemorrhages with pale centers on the sclerae, palate, buccal mucosa, chest, fingers, or toes, and are signs of extracardiac emboli. Delayed capillary refill time does not point to extracardiac emboli. Wheezing and pruritus are indicative of a hypersensitivity reaction. Erythema marginatum is a classic rash associated with acute rheumatic fever.
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A client of Eastern European descent who gave birth to her third child on the previous shift tells the nurse that she wants to get cleaned up and have something to eat so that she can be ready to go home in the morning. Which action by the nurse is approp
A) Suggest that the client take advantage of the rest since she has other children at home who will also need her care. B) Instruct the client to pace herself and that there is no hurry rush to go home. C) Assist the client with self-care requests and check on when the meals will be delivered. D) Suggest that her plans to go home depend upon her physician.
A female patient diagnosed with acute renal failure has a hemoglobin level of 12 mg/dL. The nurse plans care for a patient with which level of anemia?
1. Normal 2. Mild 3. Severe 4. Life threatening
The nurse palpates a very weak pedal pulse in the right foot. What other findings would the nurse expect to find in the right foot and leg? (Select all that apply.)
a. Bruising b. Darkened color c. Cool skin d. Diminished hair on limb e. Capillary refill of 3 seconds
A nurse is teaching childbirth education classes to a group of pregnant teens. Which strategy would promote learning by the young women?
1. Avoiding the discussion of uncomfortable procedures like vaginal exams and blood tests 2. Focusing the discussion on baby care rather than labor and delivery 3. Providing more extensive teaching and a forum for verbalization of fears and concerns 4. Having the classes at a location other than high school to reduce their embarrassment