Question 1

The child and family come to the clinic requesting information about causes of cardiac defects. The father has high incidence of cardiac defects in his family, and the child is frequently cyanotic around the lips. What causes should the nurse tell the family about? Select all that apply.

Accepted Answer

Maternal age is not a known cause of cardiac defects. However, chromosomal abnormalities, fetal exposure to maternal drugs, maternal viral infections, and maternal metabolic disorders are all potential causes of cardiac defects. Given the family history and the child's cyanotic lips, it is important to explore all possible causes with the family.

Question 2

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

Accepted Answer

Starting an intravenous line is the most appropriate intervention as the child with infective endocarditis likely needs intravenous antibiotics and/or other medications. Placing the child on contact isolation may also be necessary, but starting an IV is the most immediate priority for treatment. The child does not necessarily need seizure precautions or a lumbar puncture unless those interventions are specifically indicated for their individual case.

Question 3

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?

Accepted Answer

Kawasaki disease is characterized by symptoms such as dry, swollen, fissured lips, conjunctivitis without exudates, and palpable lymph nodes. Cyanosis is not a typical symptom.

Question 4

The family has just been informed by the healthcare provider that their newborn is diagnosed with a congenital heart defect, Tetralogy of Fallot (TOF). The family tells the nurse that the healthcare provider told them that TOF is comprised of several defects, and they ask the nurse what the defects are. What will the nurse tell the family? Select all that apply.

Accepted Answer

Tetralogy of Fallot is comprised of four defects: pulmonary stenosis, right ventricular hypertrophy, ventral septal defect, and overriding aorta. Coarctation of the aorta is not a part of TOF.

Question 5

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?

Accepted Answer

The nurse should perform a blood pressure measurement in all four extremities to assess for the presence of coarctation of the aorta, which can cause a disparity in blood pressure and pulse strength in the upper and lower extremities. Pedal pulses and pulse oximetry levels are not directly related to this issue, and hemoglobin and hematocrit values may be important for overall health assessment, but do not specifically address this issue.

Question 6

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? Select all that apply.

Accepted Answer

During a hypercyanotic episode, also known as a "tet" spell, the nurse should implement measures to increase systemic vascular resistance and decrease pulmonary vascular resistance. Placing the child in the knee-chest position can increase systemic vascular resistance by increasing venous return and decreasing the amount of blood returning to the lungs. Administering oxygen can also help to increase systemic oxygenation and decrease hypoxia. Administering medications such as morphine and propranolol can help to decrease pulmonary vascular resistance. Drawing blood for a serum hemoglobin or administering Benadryl are not appropriate interventions for a hypercyanotic episode.

Question 7

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

Accepted Answer

A capillary refill time of less than three seconds with palpable warmth indicates adequate peripheral circulation to the affected extremity. A capillary refill time greater than three seconds is considered abnormal and could indicate a circulation problem. The presence of palpable dorsalis pedis and posterior tibial pulses and a decrease in sensation are also important assessment findings, but they do not specifically indicate adequate peripheral circulation to the affected extremity.

Question 8

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?

Accepted Answer

A change in heart rhythm (such as bradycardia or tachycardia) is the initial symptom of digoxin (Lanoxin) toxicity, and should be assessed by the nurse. Lowered blood pressure, tinnitus, and ataxia are potential symptoms of digoxin toxicity, but are not typically the initial symptom.

Question 9

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?

Accepted Answer

After cardiac surgery, a child should be evaluated to determine if prophylactic antibiotics are necessary to prevent bacterial endocarditis. Dental, oral, or upper-respiratory-tract procedures could introduce bacteria into the bloodstream, which could lead to infection in the heart. The child should also receive routine immunizations, unless there are specific contraindications based on the child's condition. Restricting the child from most play activities is not necessary, and fever for several weeks following surgery is not a normal expectation.

Question 10

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 adolescent's risk? Select all that apply.

Accepted Answer

Limiting fat intake to 20 to 35 percent of total intake, encouraging participation in vigorous exercise for at least 30 minutes, and maintaining a normal weight are all effective strategies to reduce the risk of developing cardiovascular disease. Reducing smoking is not sufficient; cessation is necessary. High-fat dairy products should be limited, not included.

Question 11

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

Accepted Answer

A school-age client with pulmonary-artery hypertension needs low-impact sports or activities. Golf, which is considered a low-impact sport, can be recommended for a client with pulmonary-artery hypertension. Cross-country running, soccer, and basketball are high-impact sports that can put too much strain on the cardiovascular system, making them unsuitable for clients with pulmonary-artery hypertension.

Question 12

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

Accepted Answer

A VSD causes an increased workload on the right side of the heart, which can lead to pulmonary congestion and impaired gas exchange. Deficient fluid volume and hypothermia are not directly related to a VSD. Acute pain may be present, but it is not the most appropriate nursing diagnosis for this condition.

Question 13

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

Accepted Answer

Applying ice to the face of an infant with supravicular tachycardia can stimulate the diving reflex, which may help in slowing down the heart rate. This is a non-invasive, immediate intervention suitable for infants.

Question 14

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? Select all that apply.

Accepted Answer

The answer of The nurse is providing care to a...

Question 15

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

Accepted Answer

Tricuspid atresia leads to decreased oxygenation, causing the body to produce more red blood cells to carry oxygen, resulting in a high hemoglobin level.

Question 16

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?

Accepted Answer

Cyclosporine A is an immunosuppressant medication that helps prevent rejection of the transplanted heart by suppressing the immune system. It is not used for treating high cholesterol, hypertension, or infections. Therefore, option B is the correct answer as it accurately reflects the purpose of administering cyclosporine A in a heart transplant patient.

Question 17

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?

Accepted Answer

Tachycardia is a common symptom of congestive heart failure, as the heart attempts to compensate for its decreased ability to pump blood efficiently. Weight gain rather than weight loss is another common symptom due to fluid buildup in the body. Bradycardia and increased blood pressure are less likely to occur in CHF.

Question 18

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? Select all that apply.

Accepted Answer

Holding the infant at a 45-degree angle can help with breathing and feeding. Frequent hand hygiene is crucial to prevent infections. Notifying the healthcare provider for fever is important as it can indicate infection or other complications. Pumping and bottle feeding can help monitor intake and ensure adequate nutrition if weight gain is a concern. Feeding for 60 minutes is too long and can tire the infant.

Question 19

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

Accepted Answer

The emphasis should be on close monitoring of output because diuretics increase urine output, which can lead to electrolyte imbalances if not monitored carefully. The digitalization process, possibility of weak pulses, and increased appetite may not be as relevant to the use of a diuretic.

Quiz 21: Alterations in Cardiovascular Function