Deck 41: Nursing Care of the Child With an Alteration in Perfusion/Cardiovascular Disorder

Question 1

The nurse is conducting a physical examination of a child with a ventricular septal defect. Which finding would the nurse expect to assess?

A) Right ventricular heave
B) Holosystolic harsh murmur along the left sternal border
C) Fixed split-second heart sound
D) Systolic ejection murmur

Answer 1

Holosystolic harsh murmur along the left sternal border

Question 2

The nurse is administering digoxin as ordered and the child vomits the dose. What should the nurse do next?

A) Contact the physician
B) Offer a snack and administer another dose
C) Immediately administer another dose
D) Administer next dose as ordered in 12 hours

Answer 2

Administer next dose as ordered in 12 hours

Question 3

The nurse is caring for an infant with suspected patent ductus arteriosus. Which of the following assessment findings would the nurse identify as helping to confirm this suspicion?

A) Thrill at the base of the heart
B) Harsh, continuous, machine-like murmur under the left clavicle
C) Faint pulses
D) Systolic murmur best heard along the left sternal border

Answer 3

Harsh, continuous, machine-like murmur under the left clavicle

Question 4

The nurse is conducting a physical examination of a child with a suspected cardiovascular disorder. Which of the following findings would the nurse most likely expect to assess if the child had transposition of the great vessels?

A) Significant cyanosis without presence of a murmur
B) Abrupt cessation of chest output with an increase in heart rate/filling pressure
C) Soft systolic ejection
D) Holosystolic murmur

Question 5

The nurse is assessing a child with suspected infective endocarditis. Which of the following assessment findings would the nurse interpret as a sign of extracardiac emboli?

A) Pruritus
B) Roth spots
C) Delayed capillary refill
D) Erythema marginatum

Question 6

When conducting a physical examination of a child with suspected Kawasaki disease, which of the following would the nurse expect to assess?

A) Hirsutism or striae
B) Strawberry tongue
C) Malar rash
D) Café au lait spots

Question 7

After teaching a group of students about acute rheumatic fever, the instructor determines that the teaching was successful when the students identify which of the following as an assessment finding?

A) Janeway lesions
B) Jerky movements of the face and upper extremities
C) Black lines
D) Osler nodes

Question 8

A nurse is reviewing the medical record of a child and finds that the child has a grade III murmur. After auscultating the child's heart sounds, the nurse would document this murmur as which of the following?

A) Loud without a thrill
B) Loud with a precordial thrill
C) Soft and easily heard
D) Loud, audible with a stethoscope

Question 9

The nurse is caring for a 2-month-old infant who has been diagnosed with acute heart failure. The nurse is providing teaching about nutrition. Which of the following statements by the mother indicates a need for further teaching?

A) "The baby may need as much as 150 calories/kg/day."
B) "Small, frequent feedings are best if tolerated."
C) "I need to feed him every hour to make sure he eats enough."
D) "Gavage feedings may be required for now."

Question 10

The nurse is caring for an infant girl with a suspected cardiovascular disorder. Which of the following statements by the mother would warrant further investigation?

A) "My baby does not make any grunting noises."
B) "The baby seems more comfortable over my shoulder."
C) "The baby usually drinks all of her bottle."
D) "I don't notice any rapid breathing patterns."

Question 11

Auscultation of a child's heart reveals a loud murmur with a precordial thrill. The nurse documents this as which of the following?

A) Grade II
B) Grade III
C) Grade IV
D) Grade V

Question 12

After assessing a child's blood pressure, the nurse determines the pulse pressure and finds that it is narrowed. Which of the following would the nurse identify as associated with this finding?

A) Aortic stenosis
B) Patent ductus arteriosus
C) Aortic insufficiency
D) Complete heart block

Question 13

A 9-year-old child has undergone a cardiac catheterization and is being prepared for discharge. The nurse is instructing the parents and child about postprocedure care. Which statement by the parents indicates that the teaching was successful?

A) "This pressure dressing needs to stay on for 5 days from now."
B) "He can't eat but he can drink fluids for the next 24 hours."
C) "He should avoid taking a bath for about 3 days but he can shower."
D) "It's normal if he says he feels like his heart skipped a beat."

Question 14

A newborn is diagnosed with patent ductus arteriosus. The nurse anticipates that the physician will most likely order which medication?

A) Alprostadil
B) Heparin
C) Indomethacin
D) Spironolactone

Question 15

The nurse is preparing a teaching plan for the parents of a child who has been diagnosed with a congenital heart defect. Which of the following would the nurse be least likely to include?

A) Daily weight assessment
B) Maintenance of strict bed rest
C) Prevention of infection
D) Signs of complications

Question 16

A 7-year-old child with a family history of cardiovascular disease is being screened for hyperlipidemia. When reviewing the child's laboratory test results, which total cholesterol level would be of significant concern?

A) 120 mg/dL
B) 150 mg/dL
C) 180 mg/dL
D) 210 mg/dL

Question 17

A child with a suspected cardiovascular disorder is to undergo diagnostic testing and is scheduled for an echocardiogram. When explaining this test to the child, which of the following would the nurse most likely include?

A) "This test will check the pattern of how your heart is beating."
B) "They'll take a picture of your chest to look at the heart's size."
C) "A special wand that picks up sound is used to check your heart."
D) "Small patches are attached to your chest to check the heart rhythm."

Question 18

The nurse is reviewing the medical record of a child with infective endocarditis. Which of the following would the nurse expect to find? Select all answers that apply.

A) White blood cell count revealing leukopenia
B) Microscopic hematuria with urinalysis
C) Electrocardiogram with prolonged PR interval
D) Lungs clear on auscultation
E) Petechiae on palpebral conjunctiva

Question 19

A child with heart failure is receiving supplemental oxygen. The nurse understands that in addition to improving oxygen saturation, this intervention also helps to do which of the following?

A) Cause vasodilation
B) Increase pulmonary vascular resistance
C) Promote diuresis
D) Mobilize secretions

Question 20

The nurse is developing a plan of care for an infant with heart failure who is receiving digoxin. The nurse would hold the dose of digoxin and notify the physician if the infant's apical pulse rate was:

A) 140 beats per minute
B) 120 beats per minute
C) 100 beats per minute
D) 80 beats per minute

Question 21

A nurse is working with an adolescent who is slightly overweight and was recently diagnosed with hypertension. They are discussing nutritional management. Which statement by the adolescent demonstrates understanding of the information?

A) "I have to make sure that I don't eat a lot of salty foods."
B) "I can eat any amount at a meal as long as I don't eat between meals."
C) "I should eat plenty of fresh fruits and vegetables."
D) "If I skip breakfast, I can eat a much bigger lunch."

Question 22

A child is diagnosed with Kawasaki disease and is in the acute phase of the disorder. Which of the following would the nurse expect the physician to prescribe? Select all answers that apply.

A) Intravenous immunoglobulin
B) Ibuprofen
C) Acetaminophen
D) Aspirin
E) Alprostadil

Question 23

An infant with congenital heart disease is to undergo surgery to correct the defect. The mother states, "I guess I'm going to have to stop breastfeeding her." Which response by the nurse would be most appropriate?

A) "That's true, but we'll make sure she gets the best intravenous nutrition."
B) "Unfortunately, your baby needs more nutrients than what breast milk can provide."
C) "Breast milk may help to boost her immune system, so you can continue to use it."
D) "She won't be able to suck, so we have to give her fortified formula through a tube."

Question 24

During a follow-up visit, the parents of a 5-month-old infant diagnosed with congenital heart disease tell the nurse, "We're just so tired and emotionally spent. All these tests and examinations are overwhelming. We just want to have a normal life. We're so focused on the baby that it seems like our 3-year-old is lost in the shuffle." Which nursing diagnosis would the nurse identify as most appropriate?

A) Risk for delayed growth and development related to necessary treatments
B) Deficient knowledge related to the care of a child with congenital heart disease
C) Interrupted family processes related to demands of caring for the ill child
D) Fear related to infant's cardiac condition and need for ongoing care