MED SURG NURSING MANAGEMENT: INFLAMMATORY AND STRUCTURAL HEART DISORDERS
10.A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. Based on these findings, which nursing diagnosis would be most appropriate? A. Pain related to permanent joint fixation B. Activity intolerance related to arthralgia C. Risk for infection related to open skin lesions D. Risk for impaired skin integrity related to pruritus ANS: B The patient’s joint pain will lead to difficulty with activity. The skin lesions seen in rheumatic fever are not open or pruritic. Although acute joint pain will be a problem for this patient, joint inflammation is a temporary clinical manifestation of rheumatic fever and is not associated with permanent joint changes. DIF: Cognitive Level: Apply (application) REF: 819-820 TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 11.The nurse establishes the nursing diagnosis of ineffective health maintenance related to lack of knowledge regarding long-term management of rheumatic fever when a 30-year- old recovering from rheumatic fever without carditis says which of the following? A. “I will need prophylactic antibiotic therapy for 5 years.” B. “I will need to take aspirin or ibuprofen (Motrin) to relieve my joint pain.” C. “I will call the doctor if I develop excessive fatigue or difficulty breathing.” D. “I will be immune to further episodes of rheumatic fever after this infection.” ANS: D Patients with a history of rheumatic fever are more susceptible to a second episode. Patients with rheumatic fever without carditis require prophylaxis until age 20 and for a minimum of 5 years. The other patient statements are correct and would not support the nursing diagnosis of ineffective health maintenance.