The nurse obtains a health history from a 65-year-old patient with a prosthetic mitral valve
who has symptoms of infective endocarditis (IE). Which question by the nurse is most
appropriate?
a. “Do you have a history
...
The nurse obtains a health history from a 65-year-old patient with a prosthetic mitral valve
who has symptoms of infective endocarditis (IE). Which question by the nurse is most
appropriate?
a. “Do you have a history of a heart attack?”
b. “Is there a family history of endocarditis?”
c. “Have you had any recent immunizations?”
d. “Have you had dental work done recently?”
ANS: D
Dental procedures place the patient with a prosthetic mitral valve at risk for infective
endocarditis (IE). Myocardial infarction (MI), immunizations, and a family history of
endocarditis are not risk factors for IE.
DIF: Cognitive Level: Apply (application) REF: 812
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. During the assessment of a 25-year-old patient with infective endocarditis (IE), the nurse
would expect to find
a. substernal chest pressure.
b. a new regurgitant murmur.
c. a pruritic rash on the chest.
d. involuntary muscle movement.
ANS: B
New regurgitant murmurs occur in IE because vegetations on the valves prevent valve closure.
Substernal chest discomfort, rashes, and involuntary muscle movement are clinical
manifestations of other cardiac disorders such as angina and rheumatic fever.
DIF: Cognitive Level: Understand (comprehension) REF: 811 | 821
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular
insufficiency for the patient with infective endocarditis (IE) based on which assessment
finding(s)?
a. Fever, chills, and diaphoresis
b. Urine output less than 30 mL/hr
c. Petechiae on the inside of the mouth and conjunctiva
d. Increase in heart rate of 15 beats/minute with walking
ANS: B
Decreased renal perfusion caused by inadequate cardiac output will lead to decreased urine
output. Petechiae, fever, chills, and diaphoresis are symptoms of IE, but are not caused by
decreased cardiac output. An increase in pulse rate of 15 beats/minute is normal with exercise.
DIF: Cognitive Level: Apply (application) REF: 812
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
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