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 B
Explanation
A. While travel can expose individuals to various pathogens, Guillain-Barré syndrome (GBS) is more commonly linked to recent infections rather than overseas travel.
B. GBS is often preceded by an acute viral or bacterial infection, particularly an upper respiratory or gastrointestinal infection. This makes it essential for the nurse to inquire about a recent upper respiratory infection.
C. Taking multivitamins does not have a direct connection to the development of GBS.
D. While some vaccines are associated with GBS, the MMR vaccine is not typically a cause of concern in this context.
Correct Answer is D
Explanation
A. Applying ice to the extremity is generally not recommended for DVT due to the risk of promoting vasoconstriction and worsening the condition; warm compresses are usually indicated instead.
B. There is no need to restrict oral fluids for a client with DVT unless there are other specific medical reasons; hydration is important.
C. Vasodilating medications are not standard treatment for DVT and may not be appropriate; anticoagulants are typically the primary treatment.
D. Monitoring platelet levels is important in managing DVT, especially when anticoagulants are used, to assess for potential complications such as heparin-induced thrombocytopenia (HIT), making this option correct.