Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
What is a common, serious complication of rheumatic fever?
A. Pulmonary hypertension.
Pulmonary hypertension is not a common complication of rheumatic fever. Rheumatic fever primarily affects the heart, joints, skin, and brain, and pulmonary hypertension is not a typical manifestation of this condition.
B. Cardiac valve damage.
Cardiac valve damage is a common and serious complication of rheumatic fever. Rheumatic fever is caused by an autoimmune reaction to untreated streptococcal infections, particularly Streptococcus pyogenes. The immune response targets not only the streptococcal bacteria but also the body's own tissues, especially heart valves. This can lead to inflammation of the heart valves, a condition known as rheumatic heart disease. Over time, repeated bouts of rheumatic fever can result in significant damage to the heart valves, leading to valve insufficiency or stenosis. This can ultimately cause heart failure and other cardiovascular complications.
C. Seizures.
Seizures are not a common complication of rheumatic fever. Rheumatic fever primarily affects the heart and other body systems, but it does not typically lead to seizures.
D. Cardiac arrhythmias.
Cardiac arrhythmias are possible complications of rheumatic fever, but they are not as common or significant as cardiac valve damage. The inflammation and scarring caused by rheumatic fever can disrupt the electrical pathways of the heart, potentially leading to arrhythmias. However, the more prevalent and severe consequence of rheumatic fever is the damage to the heart valves.
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Full Explanation
The correct answer is choice B. Cardiac valve damage.
Choice A rationale:
Pulmonary hypertension is not a common complication of rheumatic fever. Rheumatic fever primarily affects the heart, joints, skin, and brain, and pulmonary hypertension is not a typical manifestation of this condition.
Choice B rationale:
Cardiac valve damage is a common and serious complication of rheumatic fever. Rheumatic fever is caused by an autoimmune reaction to untreated streptococcal infections, particularly Streptococcus pyogenes. The immune response targets not only the streptococcal bacteria but also the body's own tissues, especially heart valves. This can lead to inflammation of the heart valves, a condition known as rheumatic heart disease. Over time, repeated bouts of rheumatic fever can result in significant damage to the heart valves, leading to valve insufficiency or stenosis. This can ultimately cause heart failure and other cardiovascular complications.
Choice C rationale:
Seizures are not a common complication of rheumatic fever. Rheumatic fever primarily affects the heart and other body systems, but it does not typically lead to seizures.
Choice D rationale:
Cardiac arrhythmias are possible complications of rheumatic fever, but they are not as common or significant as cardiac valve damage. The inflammation and scarring caused by rheumatic fever can disrupt the electrical pathways of the heart, potentially leading to arrhythmias. However, the more prevalent and severe consequence of rheumatic fever is the damage to the heart valves.
Similar Questions
The nurse, caring for an infant whose cleft lip was repaired, should include which interventions in the infant's postoperative plan of care? (Select all that apply.).
A. Petroleum jelly to the suture line.
Applying petroleum jelly to the suture line is a necessary intervention in an infant's postoperative plan of care following cleft lip repair. Petroleum jelly helps to keep the suture line moist and prevents it from sticking to clothing or linens. This promotes proper healing and reduces the risk of trauma to the surgical site.
B. Elbow restraints.
Using elbow restraints is important to prevent the infant from accidentally touching or scratching the surgical site. Infants are not always able to control their movements effectively, and they may inadvertently disrupt the healing process by touching the suture line. Elbow restraints help maintain the integrity of the surgical site.
C. Supine and side-lying positions.
While positioning is important in the care of a postoperative infant, supine and side-lying positions are not specific interventions related to cleft lip repair. These positions may be used for general comfort and to prevent complications such as aspiration, but they are not directly related to the surgical site.
D. Mouth irrigations.
Mouth irrigations are not typically recommended in the postoperative care of an infant following cleft lip repair. The surgical site is in the area of the lip, not the mouth, so mouth irrigations are not directly relevant to this procedure.
E. Postural drainage.
Postural drainage is not a necessary intervention for an infant following cleft lip repair. Postural drainage is a technique used to help clear mucus and secretions from the lungs in patients with respiratory conditions. It is not applicable to the care of an infant recovering from cleft lip surgery.
Full Explanation
The correct answers are choices A, B, and D.
Choice A rationale:
Applying petroleum jelly to the suture line is a necessary intervention in an infant's postoperative plan of care following cleft lip repair. Petroleum jelly helps to keep the suture line moist and prevents it from sticking to clothing or linens. This promotes proper healing and reduces the risk of trauma to the surgical site.
Choice B rationale:
Using elbow restraints is important to prevent the infant from accidentally touching or scratching the surgical site. Infants are not always able to control their movements effectively, and they may inadvertently disrupt the healing process by touching the suture line. Elbow restraints help maintain the integrity of the surgical site.
Choice C rationale:
While positioning is important in the care of a postoperative infant, supine and side-lying positions are not specific interventions related to cleft lip repair. These positions may be used for general comfort and to prevent complications such as aspiration, but they are not directly related to the surgical site.
Choice D rationale:
Mouth irrigations are not typically recommended in the postoperative care of an infant following cleft lip repair. The surgical site is in the area of the lip, not the mouth, so mouth irrigations are not directly relevant to this procedure.
Choice E rationale:
Postural drainage is not a necessary intervention for an infant following cleft lip repair. Postural drainage is a technique used to help clear mucus and secretions from the lungs in patients with respiratory conditions. It is not applicable to the care of an infant recovering from cleft lip surgery.
What is the primary result of anemia?
A. Depressed hematopoietic system.
Anemia does not primarily result in a depressed hematopoietic system. In fact, anemia often occurs due to various factors that affect red blood cell production or lifespan. The hematopoietic system can be overactive in response to anemia, attempting to compensate for the reduced oxygen-carrying capacity of the blood.
B. Presence of abnormal hemoglobin.
While some anemias may involve the presence of abnormal hemoglobin (e.g., sickle cell anemia), this is not the primary result of anemia. The primary consequence of anemia is a decreased ability of the blood to carry oxygen to the body's tissues.
C. Decreased oxygen-carrying capacity of blood.
The correct choice. Anemia leads to a decreased oxygen-carrying capacity of the blood. Hemoglobin, the protein in red blood cells responsible for carrying oxygen, is reduced in quantity or function in various types of anemia. This results in inadequate oxygen delivery to tissues, potentially causing symptoms such as fatigue, weakness, pallor, and shortness of breath.
D. Increased blood viscosity.
Increased blood viscosity is not a primary result of anemia. Anemia tends to reduce blood viscosity because there are fewer red blood cells and less hemoglobin present, which makes the blood more fluid and less viscous. Increased blood viscosity is more commonly associated with conditions like polycythemia, where there is an excess of red blood cells.
Full Explanation
The correct answer is choice C. Decreased oxygen-carrying capacity of blood.
Choice A rationale:
Anemia does not primarily result in a depressed hematopoietic system. In fact, anemia often occurs due to various factors that affect red blood cell production or lifespan. The hematopoietic system can be overactive in response to anemia, attempting to compensate for the reduced oxygen-carrying capacity of the blood.
Choice B rationale:
While some anemias may involve the presence of abnormal hemoglobin (e.g., sickle cell anemia), this is not the primary result of anemia. The primary consequence of anemia is a decreased ability of the blood to carry oxygen to the body's tissues.
Choice C rationale:
The correct choice. Anemia leads to a decreased oxygen-carrying capacity of the blood. Hemoglobin, the protein in red blood cells responsible for carrying oxygen, is reduced in quantity or function in various types of anemia. This results in inadequate oxygen delivery to tissues, potentially causing symptoms such as fatigue, weakness, pallor, and shortness of breath.
Choice D rationale:
Increased blood viscosity is not a primary result of anemia. Anemia tends to reduce blood viscosity because there are fewer red blood cells and less hemoglobin present, which makes the blood more fluid and less viscous. Increased blood viscosity is more commonly associated with conditions like polycythemia, where there is an excess of red blood cells.
As part of the treatment for congestive heart failure, the child takes the diuretic furosemide. As part of teaching home care, the nurse encourages the family to give the child foods such as bananas, oranges, and leafy vegetables. These foods are recommended because they are high in what electrolyte?
A. Potassium.
Diuretics like furosemide are commonly used to treat congestive heart failure. They work by increasing the excretion of water and electrolytes, including potassium, from the body. Low levels of potassium (hypokalemia) can lead to various complications, including cardiac arrhythmias and muscle weakness. Since furosemide can cause potassium loss, it's important to ensure an adequate intake of potassium-rich foods. Bananas, oranges, and leafy vegetables are excellent sources of potassium. Therefore, the nurse encourages the family to include these foods in the child's diet to help maintain a healthy potassium balance.
B. Sodium.
Sodium is an important electrolyte, but in the context of congestive heart failure and diuretic use, the focus is more on avoiding excessive sodium intake. Diuretics like furosemide aim to reduce fluid retention by increasing sodium excretion, so it's not necessary to recommend high-sodium foods. Moreover, excessive sodium intake could exacerbate fluid retention and worsen the heart failure.
C. Chlorides.
Chlorides are often found in table salt (sodium chloride) and are not typically emphasized in the context of heart failure treatment or diuretic use. While they play a role in maintaining electrolyte balance, they are not the primary focus in this scenario.
D. Zinc.
Zinc is a mineral that is not directly related to the treatment of congestive heart failure or the use of diuretics. It is important for various cellular functions and immune system support, but it's not the electrolyte of concern in this situation.
Full Explanation
The correct answer is choice A. Potassium.
Choice A rationale:
Diuretics like furosemide are commonly used to treat congestive heart failure. They work by increasing the excretion of water and electrolytes, including potassium, from the body. Low levels of potassium (hypokalemia) can lead to various complications, including cardiac arrhythmias and muscle weakness. Since furosemide can cause potassium loss, it's important to ensure an adequate intake of potassium-rich foods. Bananas, oranges, and leafy vegetables are excellent sources of potassium. Therefore, the nurse encourages the family to include these foods in the child's diet to help maintain a healthy potassium balance.
Choice B rationale:
Sodium is an important electrolyte, but in the context of congestive heart failure and diuretic use, the focus is more on avoiding excessive sodium intake. Diuretics like furosemide aim to reduce fluid retention by increasing sodium excretion, so it's not necessary to recommend high-sodium foods. Moreover, excessive sodium intake could exacerbate fluid retention and worsen the heart failure.
Choice C rationale:
Chlorides are often found in table salt (sodium chloride) and are not typically emphasized in the context of heart failure treatment or diuretic use. While they play a role in maintaining electrolyte balance, they are not the primary focus in this scenario.
Choice D rationale:
Zinc is a mineral that is not directly related to the treatment of congestive heart failure or the use of diuretics. It is important for various cellular functions and immune system support, but it's not the electrolyte of concern in this situation.