Chapter 21 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 6th Edition Test Bank
Chapter 21

Question 1

Type: MCSA

The nurse has admitted a child with tricuspid atresia. The nurse would expect which initial lab result?

1. A high hemoglobin

2. A low hematocrit

3. A high white blood cell count

4. A low platelet count

Correct Answer: 1

Rationale 1: The childs bone marrow responds to chronic hypoxemia by producing more red blood cells to increase the amount of hemoglobin available to carry oxygen to the tissues. This occurs in cases of cyanotic heart defects such as tricuspid atresia. Therefore, the hematocrit would not be low, the white blood cell count would not be high (unless an infection were present), and the platelets would be normal.

Rationale 2: The childs bone marrow responds to chronic hypoxemia by producing more red blood cells to increase the amount of hemoglobin available to carry oxygen to the tissues. This occurs in cases of cyanotic heart defects such as tricuspid atresia. Therefore, the hematocrit would not be low, the white blood cell count would not be high (unless an infection were present), and the platelets would be normal.

Rationale 3: The childs bone marrow responds to chronic hypoxemia by producing more red blood cells to increase the amount of hemoglobin available to carry oxygen to the tissues. This occurs in cases of cyanotic heart defects such as tricuspid atresia. Therefore, the hematocrit would not be low, the white blood cell count would not be high (unless an infection were present), and the platelets would be normal.

Rationale 4: The childs bone marrow responds to chronic hypoxemia by producing more red blood cells to increase the amount of hemoglobin available to carry oxygen to the tissues. This occurs in cases of cyanotic heart defects such as tricuspid atresia. Therefore, the hematocrit would not be low, the white blood cell count would not be high (unless an infection were present), and the platelets would be normal.

Global Rationale: The childs bone marrow responds to chronic hypoxemia by producing more red blood cells to increase the amount of hemoglobin available to carry oxygen to the tissues. This occurs in cases of cyanotic heart defects such as tricuspid atresia. Therefore, the hematocrit would not be low, the white blood cell count would not be high (unless an infection were present), and the platelets would be normal.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 21.2 Describe the pathophysiology associated with congenital heart defects with increased pulmonary circulation, decreased pulmonary circulation, mixed defects, and obstructed systemic blood flow.

Question 2

Type: MCSA

A child has been admitted to the hospital unit in congestive heart failure (CHF). Which symptom would the nurse anticipate upon assessment of the child?

1. Weight loss

2. Bradycardia

3. Tachycardia

4. Increased blood pressure

Correct Answer: 3

Rationale 1: Tachycardia is a sign of congestive heart failure because the heart attempts to improve cardiac output by beating faster. Bradycardia is a serious sign and can indicate impending cardiac arrest. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases because of retention of fluids.

Rationale 2: Tachycardia is a sign of congestive heart failure because the heart attempts to improve cardiac output by beating faster. Bradycardia is a serious sign and can indicate impending cardiac arrest. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases because of retention of fluids.

Rationale 3: Tachycardia is a sign of congestive heart failure because the heart attempts to improve cardiac output by beating faster. Bradycardia is a serious sign and can indicate impending cardiac arrest. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases because of retention of fluids.

Rationale 4: Tachycardia is a sign of congestive heart failure because the heart attempts to improve cardiac output by beating faster. Bradycardia is a serious sign and can indicate impending cardiac arrest. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases because of retention of fluids.

Global Rationale: Tachycardia is a sign of congestive heart failure because the heart attempts to improve cardiac output by beating faster. Bradycardia is a serious sign and can indicate impending cardiac arrest. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases because of retention of fluids.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 21.6 Develop a nursing care plan for a child with congestive heart failure.

Question 3

Type: MCSA

A toddler is started on digoxin (Lanoxin) for cardiac failure. Which is the initial symptom the nurse would assess if the child develops digoxin (Lanoxin) toxicity?

1. Lowered blood pressure

2. Tinnitus

3. Ataxia

4. A change in heart rhythm

Correct Answer: 4

Rationale 1: An early sign of digoxin (Lanoxin) toxicity is a change in heart rhythm. Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in the ears), or ataxia (unsteady gait).

Rationale 2: An early sign of digoxin (Lanoxin) toxicity is a change in heart rhythm. Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in the ears), or ataxia (unsteady gait).

Rationale 3: An early sign of digoxin (Lanoxin) toxicity is a change in heart rhythm. Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in the ears), or ataxia (unsteady gait).

Rationale 4: An early sign of digoxin (Lanoxin) toxicity is a change in heart rhythm. Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in the ears), or ataxia (unsteady gait).

Global Rationale: An early sign of digoxin (Lanoxin) toxicity is a change in heart rhythm. Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in the ears), or ataxia (unsteady gait).

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 21.5 Recognize the signs and symptoms of congestive heart failure in an infant and child.

Question 4

Type: MCSA

The nurse is checking peripheral perfusion to a childs extremity following a cardiac catheterization. Which assessment finding indicates adequate peripheral circulation to the affected extremity?

1. A capillary refill of greater than three seconds

2. A palpable dorsalis pedis pulse but a weak posterior tibial pulse

3. A decrease in sensation with a weakened dorsalis pedis pulse

4. A capillary refill of less than three seconds with palpable warmth

Correct Answer: 4

Rationale 1: The nurse checks the extremity to determine adequacy of circulation following a cardiac catheterization. An extremity that is warm with capillary refill of less than three seconds has adequate circulation. Other indicators of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate sensation, and pinkness of skin color. If the capillary refill is over three seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation may not be adequate.

Rationale 2: The nurse checks the extremity to determine adequacy of circulation following a cardiac catheterization. An extremity that is warm with capillary refill of less than three seconds has adequate circulation. Other indicators of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate sensation, and pinkness of skin color. If the capillary refill is over three seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation may not be adequate.

Rationale 3: The nurse checks the extremity to determine adequacy of circulation following a cardiac catheterization. An extremity that is warm with capillary refill of less than three seconds has adequate circulation. Other indicators of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate sensation, and pinkness of skin color. If the capillary refill is over three seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation may not be adequate.

Rationale 4: The nurse checks the extremity to determine adequacy of circulation following a cardiac catheterization. An extremity that is warm with capillary refill of less than three seconds has adequate circulation. Other indicators of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate sensation, and pinkness of skin color. If the capillary refill is over three seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation may not be adequate.

Global Rationale: The nurse checks the extremity to determine adequacy of circulation following a cardiac catheterization. An extremity that is warm with capillary refill of less than three seconds has adequate circulation. Other indicators of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate sensation, and pinkness of skin color. If the capillary refill is over three seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation may not be adequate.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 21.1 Describe the anatomy and physiology of the cardiovascular system, focusing on the flow of blood and the action of heart valves.

Question 5

Type: MCSA

The nurse admits a child with a ventricular septal defect (VSD) to the unit. Which nursing diagnosis for this child is the most appropriate?

1. Impaired Gas Exchange Related to Pulmonary Congestion Secondary to the Increased Pulmonary Blood Flow

2. Deficient Fluid Volume Related to Hyperthermia Secondary to the Congenital Heart Defect

3. Acute Pain Related to the Effects of a Congenital Heart Defect

4. Hypothermia Related to Decreased Metabolic State

Correct Answer: 1

Rationale 1: Because of the increased pulmonary congestion, Impaired Gas Exchange would be an appropriate nursing diagnosis. Ventricular septal defects do not cause pain, fever, or deficient fluid volume.

Rationale 2: Because of the increased pulmonary congestion, Impaired Gas Exchange would be an appropriate nursing diagnosis. Ventricular septal defects do not cause pain, fever, or deficient fluid volume.

Rationale 3: Because of the increased pulmonary congestion, Impaired Gas Exchange would be an appropriate nursing diagnosis. Ventricular septal defects do not cause pain, fever, or deficient fluid volume.

Rationale 4: Because of the increased pulmonary congestion, Impaired Gas Exchange would be an appropriate nursing diagnosis. Ventricular septal defects do not cause pain, fever, or deficient fluid volume.

Global Rationale: Because of the increased pulmonary congestion, Impaired Gas Exchange would be an appropriate nursing diagnosis. Ventricular septal defects do not cause pain, fever, or deficient fluid volume.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort 

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 21.2 Describe the pathophysiology associated with congenital heart defects with increased pulmonary circulation, decreased pulmonary circulation, mixed defects, and obstructed systemic blood flow.

Question 6

Type: MCSA

The nurse is teaching the parents of a group of cardiac patients. Which teaching guideline will the nurse include for any child who has undergone cardiac surgery?

1. The child should be restricted from most play activities.

2. The child should be evaluated to determine if prophylactic antibiotics for dental, oral, or upper-respiratory-tract procedures are necessary.

3. The child should not receive routine immunizations.

4. The child can be expected to have a fever for several weeks following the surgery.

Correct Answer: 2

Rationale 1: Parents should be taught that the child may need prophylactic antibiotics for some dental procedures, according to the American Heart Association, to prevent endocarditis. The child should live a normal and active life following repair of a cardiac defect. Immunizations should be provided according to the schedule, and any unexplained fever should be reported.

Rationale 2: Parents should be taught that the child may need prophylactic antibiotics for some dental procedures, according to the American Heart Association, to prevent endocarditis. The child should live a normal and active life following repair of a cardiac defect. Immunizations should be provided according to the schedule, and any unexplained fever should be reported.

Rationale 3: Parents should be taught that the child may need prophylactic antibiotics for some dental procedures, according to the American Heart Association, to prevent endocarditis. The child should live a normal and active life following repair of a cardiac defect. Immunizations should be provided according to the schedule, and any unexplained fever should be reported.

Rationale 4: Parents should be taught that the child may need prophylactic antibiotics for some dental procedures, according to the American Heart Association, to prevent endocarditis. The child should live a normal and active life following repair of a cardiac defect. Immunizations should be provided according to the schedule, and any unexplained fever should be reported.

Global Rationale: Parents should be taught that the child may need prophylactic antibiotics for some dental procedures, according to the American Heart Association, to prevent endocarditis. The child should live a normal and active life following repair of a cardiac defect. Immunizations should be provided according to the schedule, and any unexplained fever should be reported.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 21.4 Create a nursing care plan for the child undergoing open heart surgery.

Question 7

Type: MCMA

An infant with tetralogy of Fallot is having a hypercyanotic episode (tet spell). Which nursing interventions are appropriate for the nurse to implement for this infant?

Standard Text: Select all that apply.

1. Place the child in knee-chest position.

2. Draw blood for a serum hemoglobin.

3. Administer oxygen.

4. Administer morphine and propranolol intravenously as ordered.

5. Administer Benadryl as ordered.

Correct Answer: 1,3,4

Rationale 1: When an infant with tetralogy of Fallot has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities), and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). The nurse would not draw blood until the episode had subsided, because unpleasant procedures are postponed. Benadryl is not appropriate for this child.

Rationale 2: When an infant with tetralogy of Fallot has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities), and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). The nurse would not draw blood until the episode had subsided, because unpleasant procedures are postponed. Benadryl is not appropriate for this child.

Rationale 3: When an infant with tetralogy of Fallot has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities), and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). The nurse would not draw blood until the episode had subsided, because unpleasant procedures are postponed. Benadryl is not appropriate for this child.

Rationale 4: When an infant with tetralogy of Fallot has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities), and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). The nurse would not draw blood until the episode had subsided, because unpleasant procedures are postponed. Benadryl is not appropriate for this child.

Rationale 5: When an infant with tetralogy of Fallot has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities), and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). The nurse would not draw blood until the episode had subsided, because unpleasant procedures are postponed. Benadryl is not appropriate for this child.

Global Rationale: When an infant with tetralogy of Fallot has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities), and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). The nurse would not draw blood until the episode had subsided, because unpleasant procedures are postponed. Benadryl is not appropriate for this child.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 21.2 Describe the pathophysiology associated with congenital heart defects with increased pulmonary circulation, decreased pulmonary circulation, mixed defects, and obstructed systemic blood flow.

Question 8

Type: MCSA

A child recently had a heart transplant and the nurse teaches the parents the importance of administering cyclosporine A. Which statement by the parents indicates an appropriate understanding of the teaching session?

1. Cyclosporin A reduces serum-cholesterol level.

2. Cyclosporin A prevents rejection.

3. Cyclosporin A treats hypertension.

4. Cyclosporin A treats infections.

Correct Answer: 2

Rationale 1: Cyclosporin A is given to prevent rejection. Lovastatin is given to reduce serum-cholesterol level, calcium channel blockers may be used to treat hypertension, and an antibiotic may be given to treat an infection.

Rationale 2: Cyclosporin A is given to prevent rejection. Lovastatin is given to reduce serum-cholesterol level, calcium channel blockers may be used to treat hypertension, and an antibiotic may be given to treat an infection.

Rationale 3: Cyclosporin A is given to prevent rejection. Lovastatin is given to reduce serum-cholesterol level, calcium channel blockers may be used to treat hypertension, and an antibiotic may be given to treat an infection.

Rationale 4: Cyclosporin A is given to prevent rejection. Lovastatin is given to reduce serum-cholesterol level, calcium channel blockers may be used to treat hypertension, and an antibiotic may be given to treat an infection.

Global Rationale: Cyclosporin A is given to prevent rejection. Lovastatin is given to reduce serum-cholesterol level, calcium channel blockers may be used to treat hypertension, and an antibiotic may be given to treat an infection.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 21.4 Create a nursing care plan for the child undergoing open heart surgery.

Question 9

Type: MCSA

Which athletic activity can the nurse recommend for a school-age client with pulmonary-artery hypertension?

1. Cross-country running

2. Soccer

3. Golf

4. Basketball

Correct Answer: 3

Rationale 1: A child with pulmonary-artery hypertension should have exercise tailored to avoid dyspnea. Golf would require less exertion than soccer, basketball, or cross-country running.

Rationale 2: A child with pulmonary-artery hypertension should have exercise tailored to avoid dyspnea. Golf would require less exertion than soccer, basketball, or cross-country running.

Rationale 3: A child with pulmonary-artery hypertension should have exercise tailored to avoid dyspnea. Golf would require less exertion than soccer, basketball, or cross-country running.

Rationale 4: A child with pulmonary-artery hypertension should have exercise tailored to avoid dyspnea. Golf would require less exertion than soccer, basketball, or cross-country running.

Global Rationale: A child with pulmonary-artery hypertension should have exercise tailored to avoid dyspnea. Golf would require less exertion than soccer, basketball, or cross-country running.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 21.7 Differentiate among the heart diseases that are acquired during childhood.

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Question 10

Type: MCSA

A child is admitted with infective endocarditis. Which nursing intervention is most appropriate for this child?

1. Start an intravenous line.

2. Place the child in contact isolation.

3. Place the child on seizure precautions.

4. Assist with a lumbar puncture.

Correct Answer: 1

Rationale 1: Infective endocarditis is treated with intravenous antibiotics for two to eight weeks. It is not contagious, so the child is not placed in contact isolation. Seizures are not a risk of infective endocarditis. A lumbar puncture is not a diagnostic test done for infective endocarditis.

Rationale 2: Infective endocarditis is treated with intravenous antibiotics for two to eight weeks. It is not contagious, so the child is not placed in contact isolation. Seizures are not a risk of infective endocarditis. A lumbar puncture is not a diagnostic test done for infective endocarditis.

Rationale 3: Infective endocarditis is treated with intravenous antibiotics for two to eight weeks. It is not contagious, so the child is not placed in contact isolation. Seizures are not a risk of infective endocarditis. A lumbar puncture is not a diagnostic test done for infective endocarditis.

Rationale 4: Infective endocarditis is treated with intravenous antibiotics for two to eight weeks. It is not contagious, so the child is not placed in contact isolation. Seizures are not a risk of infective endocarditis. A lumbar puncture is not a diagnostic test done for infective endocarditis.

Global Rationale: Infective endocarditis is treated with intravenous antibiotics for two to eight weeks. It is not contagious, so the child is not placed in contact isolation. Seizures are not a risk of infective endocarditis. A lumbar puncture is not a diagnostic test done for infective endocarditis.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 21.1 Describe the anatomy and physiology of the cardiovascular system, focusing on the flow of blood and the action of heart valves.

Question 11

Type: MCSA

The mother of a child with a heart defect is questioning the nurse about the childs diuretic. When teaching the mother about the medication, what should the emphasis from the nurse?

1. Close monitoring of output

2. The digitalization process

3. The possibility that pulses in the child might be weak

4. The childs increased appetite

Correct Answer: 1

Rationale 1: It is important to monitor the output of the child on a diuretic to determine effectiveness of the drug. Digitalization pulses are not associated with diuretics. The child will usually have a decreased appetite.

Rationale 2: It is important to monitor the output of the child on a diuretic to determine effectiveness of the drug. Digitalization pulses are not associated with diuretics. The child will usually have a decreased appetite.

Rationale 3: It is important to monitor the output of the child on a diuretic to determine effectiveness of the drug. Digitalization pulses are not associated with diuretics. The child will usually have a decreased appetite.

Rationale 4: It is important to monitor the output of the child on a diuretic to determine effectiveness of the drug. Digitalization pulses are not associated with diuretics. The child will usually have a decreased appetite.

Global Rationale: It is important to monitor the output of the child on a diuretic to determine effectiveness of the drug. Digitalization pulses are not associated with diuretics. The child will usually have a decreased appetite.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 21.2 Describe the pathophysiology associated with congenital heart defects with increased pulmonary circulation, decreased pulmonary circulation, mixed defects, and obstructed systemic blood flow.

Question 12

Type: MCSA

The nurse is performing the initial assessment of a child newly diagnosed Kawasaki disease. Which symptoms would the nurse expect to assess with this child?

1. Dry, swollen, fissured lips

2. Non-palpable lymph nodes

3. Conjunctivitis with exudates

4. Cyanosis of the hands and feet

Correct Answer: 1

Rationale 1: Dry, swollen, fissured lips are symptoms of Kawasaki disease. Lymph nodes can be palpable, conjunctivitis is present but without exudates, and hands and feet are typically erythematous.

Rationale 2: Dry, swollen, fissured lips are symptoms of Kawasaki disease. Lymph nodes can be palpable, conjunctivitis is present but without exudates, and hands and feet are typically erythematous.

Rationale 3: Dry, swollen, fissured lips are symptoms of Kawasaki disease. Lymph nodes can be palpable, conjunctivitis is present but without exudates, and hands and feet are typically erythematous.

Rationale 4: Dry, swollen, fissured lips are symptoms of Kawasaki disease. Lymph nodes can be palpable, conjunctivitis is present but without exudates, and hands and feet are typically erythematous.

Global Rationale: Dry, swollen, fissured lips are symptoms of Kawasaki disease. Lymph nodes can be palpable, conjunctivitis is present but without exudates, and hands and feet are typically erythematous.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 21.7 Differentiate among the heart diseases that are acquired during childhood.

Question 13

Type: MCSA

The nurse finds that an infant has stronger pulses in the upper extremities than in the lower extremities, and higher blood pressure readings in the arms than in the legs. Which assessment will the nurse perform next on this infant?

1. Pedal pulses

2. Pulse oximetry level

3. Hemoglobin and hematocrit values

4. Blood pressure of the four extremities

Correct Answer: 4

Rationale 1: Coarctation of the aorta can present with stronger pulses in the upper extremities than in the lower extremities and higher blood pressure readings in the arms than in the legs because of obstruction of circulation to the lower extremities. Blood pressure values of the four limbs should be the next assessment data collected. Pedal pulses, pulse oximetry, and labs themselves will not provide the data needed.

Rationale 2: Coarctation of the aorta can present with stronger pulses in the upper extremities than in the lower extremities and higher blood pressure readings in the arms than in the legs because of obstruction of circulation to the lower extremities. Blood pressure values of the four limbs should be the next assessment data collected. Pedal pulses, pulse oximetry, and labs themselves will not provide the data needed.

Rationale 3: Coarctation of the aorta can present with stronger pulses in the upper extremities than in the lower extremities and higher blood pressure readings in the arms than in the legs because of obstruction of circulation to the lower extremities. Blood pressure values of the four limbs should be the next assessment data collected. Pedal pulses, pulse oximetry, and labs themselves will not provide the data needed.

Rationale 4: Coarctation of the aorta can present with stronger pulses in the upper extremities than in the lower extremities and higher blood pressure readings in the arms than in the legs because of obstruction of circulation to the lower extremities. Blood pressure values of the four limbs should be the next assessment data collected. Pedal pulses, pulse oximetry, and labs themselves will not provide the data needed.

Global Rationale: Coarctation of the aorta can present with stronger pulses in the upper extremities than in the lower extremities and higher blood pressure readings in the arms than in the legs because of obstruction of circulation to the lower extremities. Blood pressure values of the four limbs should be the next assessment data collected. Pedal pulses, pulse oximetry, and labs themselves will not provide the data needed.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 21.2 Describe the pathophysiology associated with congenital heart defects with increased pulmonary circulation, decreased pulmonary circulation, mixed defects, and obstructed systemic blood flow.

Question 14

Type: MCSA

The nurse is admitting an infant diagnosed with supraventricular tachycardia. Which intervention is the priority for this infant?

1. Apply ice to the face.

2. Perform Valsalvas maneuver.

3. Administer a beta blocker.

4. Prepare for cardioversion.

Correct Answer: 1

Rationale 1: Supraventricular tachycardia episodes are initially treated with vagal maneuvers to slow the heart rate when the infant is stable. In stable infants, the application of ice or iced saline solution to the face can reduce the heart rate. The infant is not capable of performing Valsalvas maneuver. Calcium channel blockers, not beta blockers, are the drugs of choice. Cardioversion is used in an urgent situation, but is not typically the initial treatment.

Rationale 2: Supraventricular tachycardia episodes are initially treated with vagal maneuvers to slow the heart rate when the infant is stable. In stable infants, the application of ice or iced saline solution to the face can reduce the heart rate. The infant is not capable of performing Valsalvas maneuver. Calcium channel blockers, not beta blockers, are the drugs of choice. Cardioversion is used in an urgent situation, but is not typically the initial treatment.

Rationale 3: Supraventricular tachycardia episodes are initially treated with vagal maneuvers to slow the heart rate when the infant is stable. In stable infants, the application of ice or iced saline solution to the face can reduce the heart rate. The infant is not capable of performing Valsalvas maneuver. Calcium channel blockers, not beta blockers, are the drugs of choice. Cardioversion is used in an urgent situation, but is not typically the initial treatment.

Rationale 4: Supraventricular tachycardia episodes are initially treated with vagal maneuvers to slow the heart rate when the infant is stable. In stable infants, the application of ice or iced saline solution to the face can reduce the heart rate. The infant is not capable of performing Valsalvas maneuver. Calcium channel blockers, not beta blockers, are the drugs of choice. Cardioversion is used in an urgent situation, but is not typically the initial treatment.

Global Rationale: Supraventricular tachycardia episodes are initially treated with vagal maneuvers to slow the heart rate when the infant is stable. In stable infants, the application of ice or iced saline solution to the face can reduce the heart rate. The infant is not capable of performing Valsalvas maneuver. Calcium channel blockers, not beta blockers, are the drugs of choice. Cardioversion is used in an urgent situation, but is not typically the initial treatment.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 21.2 Describe the pathophysiology associated with congenital heart defects with increased pulmonary circulation, decreased pulmonary circulation, mixed defects, and obstructed systemic blood flow.

Question 15

Type: MCMA

The nurse is preparing to discharge an infant with a congenital heart defect. The infant will be cared for at home by the parents until surgery. Which items will the nurse include in the discharge teaching for this infant and family?

Standard Text: Select all that apply.

1. Allow the infant to feed for 60 minutes.

2. Hold the infant at a 45 degree angle.

3. Encourage frequent hand hygiene.

4. Notify the health care provider for fever.

5. Pump the breasts and feed with a bottle if weight gain is an issue.

Correct Answer: 2,3,4,5

Rationale 1: Children are often managed at home until surgery. The parents should hold the infant at a 45 degree angle to decrease tachypnea. The parents should also encourage frequent hand hygiene to decrease the risk of infection. It is important to notify the health care provider for a fever, as the infant will be at risk for dehydration and digoxin toxicity. If the mother is breastfeeding and the infant is losing weight, the mother should be encouraged to pump the milk and feed the infant from a bottle, but each feeding should be limited to 30 minutes. Tube feedings may be needed for this infant to conserve calories expenditure.

Rationale 2: Children are often managed at home until surgery. The parents should hold the infant at a 45 degree angle to decrease tachypnea. The parents should also encourage frequent hand hygiene to decrease the risk of infection. It is important to notify the health care provider for a fever, as the infant will be at risk for dehydration and digoxin toxicity. If the mother is breastfeeding and the infant is losing weight, the mother should be encouraged to pump the milk and feed the infant from a bottle, but each feeding should be limited to 30 minutes. Tube feedings may be needed for this infant to conserve calories expenditure.

Rationale 3: Children are often managed at home until surgery. The parents should hold the infant at a 45 degree angle to decrease tachypnea. The parents should also encourage frequent hand hygiene to decrease the risk of infection. It is important to notify the health care provider for a fever, as the infant will be at risk for dehydration and digoxin toxicity. If the mother is breastfeeding and the infant is losing weight, the mother should be encouraged to pump the milk and feed the infant from a bottle, but each feeding should be limited to 30 minutes. Tube feedings may be needed for this infant to conserve calories expenditure.

Rationale 4: Children are often managed at home until surgery. The parents should hold the infant at a 45 degree angle to decrease tachypnea. The parents should also encourage frequent hand hygiene to decrease the risk of infection. It is important to notify the health care provider for a fever, as the infant will be at risk for dehydration and digoxin toxicity. If the mother is breastfeeding and the infant is losing weight, the mother should be encouraged to pump the milk and feed the infant from a bottle, but each feeding should be limited to 30 minutes. Tube feedings may be needed for this infant to conserve calories expenditure.

Rationale 5: Children are often managed at home until surgery. The parents should hold the infant at a 45 degree angle to decrease tachypnea. The parents should also encourage frequent hand hygiene to decrease the risk of infection. It is important to notify the health care provider for a fever, as the infant will be at risk for dehydration and digoxin toxicity. If the mother is breastfeeding and the infant is losing weight, the mother should be encouraged to pump the milk and feed the infant from a bottle, but each feeding should be limited to 30 minutes. Tube feedings may be needed for this infant to conserve calories expenditure.

Global Rationale: Children are often managed at home until surgery. The parents should hold the infant at a 45 degree angle to decrease tachypnea. The parents should also encourage frequent hand hygiene to decrease the risk of infection. It is important to notify the health care provider for a fever, as the infant will be at risk for dehydration and digoxin toxicity. If the mother is breastfeeding and the infant is losing weight, the mother should be encouraged to pump the milk and feed the infant from a bottle, but each feeding should be limited to 30 minutes. Tube feedings may be needed for this infant to conserve calories expenditure.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 21.3 Develop a nursing care plan for the infant with a congenital heart defect cared for at home prior to corrective surgery.

Question 16

Type: MCMA

The nurse is providing care to an adolescent child who is at risk for developing adult-onset cardiovascular disease. Which teaching points will decrease the adolescents risk?

Standard Text: Select all that apply.

1. Encourage a decrease in smoking.

2. Limit fat intake to 20% to 35% of intake.

3. Encourage participation in vigorous exercise for at least 30 minutes.

4. Maintain a normal weight.

5. Include high-fat dairy products in the daily diet.

Correct Answer: 2,3,4

Rationale 1: Teaching points that will decrease the adolescents risk of developing adult-onset cardiovascular disease include: limiting fat intake to 20% to 35% of total daily intake; encouraging the participation in vigorous exercise at least 30 minutes each day; and maintaining a normal weight. The adolescent and family members should be encouraged to stop smoking, not just to decrease smoking. The family should be educated to include low-fat dairy products in the daily diet.

Rationale 2: Teaching points that will decrease the adolescents risk of developing adult-onset cardiovascular disease include: limiting fat intake to 20% to 35% of total daily intake; encouraging the participation in vigorous exercise at least 30 minutes each day; and maintaining a normal weight. The adolescent and family members should be encouraged to stop smoking, not just to decrease smoking. The family should be educated to include low-fat dairy products in the daily diet.

Rationale 3: Teaching points that will decrease the adolescents risk of developing adult-onset cardiovascular disease include: limiting fat intake to 20% to 35% of total daily intake; encouraging the participation in vigorous exercise at least 30 minutes each day; and maintaining a normal weight. The adolescent and family members should be encouraged to stop smoking, not just to decrease smoking. The family should be educated to include low-fat dairy products in the daily diet.

Rationale 4: Teaching points that will decrease the adolescents risk of developing adult-onset cardiovascular disease include: limiting fat intake to 20% to 35% of total daily intake; encouraging the participation in vigorous exercise at least 30 minutes each day; and maintaining a normal weight. The adolescent and family members should be encouraged to stop smoking, not just to decrease smoking. The family should be educated to include low-fat dairy products in the daily diet.

Rationale 5: Teaching points that will decrease the adolescents risk of developing adult-onset cardiovascular disease include: limiting fat intake to 20% to 35% of total daily intake; encouraging the participation in vigorous exercise at least 30 minutes each day; and maintaining a normal weight. The adolescent and family members should be encouraged to stop smoking, not just to decrease smoking. The family should be educated to include low-fat dairy products in the daily diet.

Global Rationale: Teaching points that will decrease the adolescents risk of developing adult-onset cardiovascular disease include: limiting fat intake to 20% to 35% of total daily intake; encouraging the participation in vigorous exercise at least 30 minutes each day; and maintaining a normal weight. The adolescent and family members should be encouraged to stop smoking, not just to decrease smoking. The family should be educated to include low-fat dairy products in the daily diet.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 21.8 List strategies to reduce a childs risk of adult-onset cardiovascular disease.

Question 17

Type: MCMA

The nurse is providing care to a school-age client admitted to the emergency department following a motor vehicle crash. The client is exhibiting symptoms of hypovolemic shock. Which nursing interventions are appropriate for this client?

Standard Text: Select all that apply.

1. Monitor hemoglobin and hematocrit.

2. Monitor liver enzymes.

3. Administer oxygen, as needed.

4. Administer a dextrose solution.

5. Monitor blood glucose.

Correct Answer: 1,3,5

Rationale 1: Nursing care for a client experiencing hypovolemic shock is aimed at monitoring the childs condition and response to clinical therapy. It is appropriate for the nurse to monitor hemoglobin, hematocrit, and blood glucose. The nurse will also administer oxygen. The nurse will administer large volumes of crystalloid fluids (normal saline or lactated Ringers), not dextrose. It is not necessary to monitor liver enzymes for this client.

Rationale 2: Nursing care for a client experiencing hypovolemic shock is aimed at monitoring the childs condition and response to clinical therapy. It is appropriate for the nurse to monitor hemoglobin, hematocrit, and blood glucose. The nurse will also administer oxygen. The nurse will administer large volumes of crystalloid fluids (normal saline or lactated Ringers), not dextrose. It is not necessary to monitor liver enzymes for this client.

Rationale 3: Nursing care for a client experiencing hypovolemic shock is aimed at monitoring the childs condition and response to clinical therapy. It is appropriate for the nurse to monitor hemoglobin, hematocrit, and blood glucose. The nurse will also administer oxygen. The nurse will administer large volumes of crystalloid fluids (normal saline or lactated Ringers), not dextrose. It is not necessary to monitor liver enzymes for this client.

Rationale 4: Nursing care for a client experiencing hypovolemic shock is aimed at monitoring the childs condition and response to clinical therapy. It is appropriate for the nurse to monitor hemoglobin, hematocrit, and blood glucose. The nurse will also administer oxygen. The nurse will administer large volumes of crystalloid fluids (normal saline or lactated Ringers), not dextrose. It is not necessary to monitor liver enzymes for this client.

Rationale 5: Nursing care for a client experiencing hypovolemic shock is aimed at monitoring the childs condition and response to clinical therapy. It is appropriate for the nurse to monitor hemoglobin, hematocrit, and blood glucose. The nurse will also administer oxygen. The nurse will administer large volumes of crystalloid fluids (normal saline or lactated Ringers), not dextrose. It is not necessary to monitor liver enzymes for this client.

Global Rationale: Nursing care for a client experiencing hypovolemic shock is aimed at monitoring the childs condition and response to clinical therapy. It is appropriate for the nurse to monitor hemoglobin, hematocrit, and blood glucose. The nurse will also administer oxygen. The nurse will administer large volumes of crystalloid fluids (normal saline or lactated Ringers), not dextrose. It is not necessary to monitor liver enzymes for this client.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 21.9 Plan the nursing management of hypovolemic shock.

Ball/Bindler/Cowen, Principles of Pediatric Nursing 6th Ed. Test Bank

Copyright 2015 by Pearson Education, Inc.

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