A nurse is assisting with the care of a client who has infective endocarditis. Which of the following manifestations should the nurse identify as a complication of this disorder?
Dyspnea
Fever
Petechiae
A heart murmur
The Correct Answer is A
A. Dyspnea can indicate heart failure or embolic events resulting from infective endocarditis, making it a serious complication that warrants attention.
B. Fever is a common symptom of infective endocarditis due to the infection but is not a complication; rather, it is part of the disease process.
C. Petechiae are small red or purple spots that can occur with infective endocarditis but are also not considered a complication, rather a manifestation of the condition.
D. A heart murmur may be present due to valvular damage but is not classified as a complication; it is a common finding in infective endocarditis.
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Correct Answer is C
Explanation
A. Monitoring electrolyte levels is important but is not as immediate as ensuring airway patency.
B. Performing passive range of motion is beneficial for mobility but does not address the immediate needs of an unconscious patient.
C. Suctioning saliva from the client's mouth is the highest priority intervention, as maintaining airway clearance is critical to prevent aspiration and ensure adequate ventilation.
D. Recording intake and output is necessary for overall assessment but is not as urgent as managing the airway.
Correct Answer is A
Explanation
A. A positive result in a Tensilon test is indicated by a temporary improvement in muscle strength following the administration of edrophonium (Tensilon), confirming the diagnosis of myasthenia gravis.
B. A "pill-rolling" tremor is associated with Parkinson's disease, not myasthenia gravis, and is not relevant to this test.
C. While muscle electrical activity can be assessed in other tests, the Tensilon test specifically evaluates muscle strength changes, not electrical charge intensity.
D. No change in muscle strength would suggest a negative result for myasthenia gravis, indicating that the test did not confirm the diagnosis.