A child diagnosed with a ventricular septal defect (VSD) is seen in the clinic. The nurse conducts an assessment and reviews the child's recent laboratory results. The nurse suspects the child may have developed heart failure. Which finding is the best indicator of the nurse's suspicion? - low hema...
NUR 370 - Exam 3 Practice Questions
and Solutions
A child diagnosed with a ventricular septal defect (VSD) is seen in the clinic. The nurse
conducts an assessment and reviews the child's recent laboratory results. The nurse
suspects the child may have developed heart failure. Which finding is the best indicator
of the nurse's suspicion?
- low hematocrit
- reports of increased fatigue
- crackles on lung auscultation
- poor weight gain ✅Crackles on lung auscultation
Crackles on auscultation of the lungs are the best indicator that the child has developed
heart failure. This indicates pulmonary congestion and is a progressive finding in heart
failure. Reports of increased fatigue and lack of weight gain are related to the ventricular
septal defect (VSD) but do not necessarily indicate the development of heart failure.
Anemia could also be associated with the VSD because it relates to poor feeding and
lack of weight gain.
A group of nurses is reviewing the diagnosis of cystic fibrosis. With regard to the effect
of this disease on the body, which parts of the body (besides the lungs) are most
affected by this disease?
- Brain and spinal cord
- Pancreas and liver
- Heart and blood vessels
- Kidney and bladder ✅Pancreas and liver
The major organs affected are the lungs, pancreas, and liver. The brain, spinal cord,
heart, blood vessels, kidney and bladder are not the most affected organs.
The nurse teaches a mother pain management techniques to use for a toddler with otitis
media. Which statement indicates that the mother needs additional teaching?
- "I should give my toddler one baby aspirin."
- "Use of infant Tylenol is good for my toddler."
- "I don't have to give my child pain medication unless it is needed."
- "Ibuprofen can be purchased over the counter to use if my toddler needs it." ✅"I
should give my toddler one baby aspirin."
Children should not receive acetylsalicylic acid or aspirin for pain relief because there is
an association between aspirin administration and the development of Reye syndrome.
Infant Tylenol and ibuprofen are safe to use with children for pain control. The child
should not receive pain medication unless it is needed.
,The nurse is teaching the caregivers of a child with cystic fibrosis. What is most
important for the nurse to teach this family?
- Be sure the child exercises daily.
- Watch out for signs that family members are overly stressed.
- Avoid overprotecting the child.
- Encourage everyone in the family to use good handwashing techniques.
✅Encourage everyone in the family to use good handwashing techniques.
The child with cystic fibrosis has low resistance, especially to respiratory infections. For
this reason, take care to protect the child from any exposure to infectious organisms.
Good handwashing techniques should be practiced by the whole family; teach the child
and family the importance of this first line of defense. Practice and teach other good
hygiene habits.
A parent brings an infant in for poor feeding and listlessness. Which assessment data
would most likely indicate a coarctation of the aorta?
- Pulses weaker in lower extremities compared to upper extremities
- Pulses weaker in upper extremities compared to lower extremities
- Cyanosis with crying
- Cyanosis with feeding ✅Pulses weaker in lower extremities compared to upper
extremities
With coarctation of the aorta there is a narrowing causing the blood flow to be impeded.
This produces increased pressure in the areas proximal to the narrowing and a
decrease in pressures distal to the narrowing. Thus, the infant would have decreased
systemic circulation. The upper half of the body would have an increased B/P and be
well perfused with strong pulses. The lower half of the body would have decreased B/P
with poorer perfusion and weaker pulses. Coarctation is not a cyanotic defect. The
cyanosis would be associated with tetralogy of Fallot.
A 5-year-old child is brought to the emergency department with reports of generalized
pain, especially in the right hand, for several hours. The nurse completes an
assessment (above). Which condition is associated with these findings?
The assessment findings are associated with a sickle cell disease vaso-occlusive crisis.
Vaso-occlusive crisis robs the tissues of oxygen and results in ischemic infarcts at the
site of the occlusion, which is extremely painful and can occur anywhere the blood
flows. Young children often experience painful edema and erythema in the hands and
, feet that is called dactylitis. Aplastic anemia and beta-thalassemia do not present with
swollen and tender extremities. Children diagnosed with hemophilia B can have edema,
erythema, and pain after bleeding in a joint secondary to an injury, but not signs
associated with hypoxia (oxygen saturation below 93%, tachypnea, tachycardia).
A nurse is reading a journal article about congenital heart conditions that are associated
with decreased pulmonary blood flow. The nurse demonstrates understanding of the
information when she identifies which anomalies as being associated with tetralogy of
Fallot? Select all that apply.
Tetralogy of Fallot is a congenital heart defect composed of four heart defects:
pulmonary stenosis (a narrowing of the pulmonary valve and outflow tract, creating an
obstruction of blood flow from the right ventricle to the pulmonary artery); ventricular
septal defect; overriding aorta (enlargement of the aortic valve to the extent that it
appears to arise from the right and left ventricles rather than the anatomically correct left
ventricle); and right ventricular hypertrophy (the muscle walls of the right ventricle
increase in size due to continued overuse as the right ventricle attempts to overcome a
high-pressure gradient).
The nurse is caring for a young child with HIV. Which nursing intervention is a priority
for this child?
- Administer prescribed medications.
- Assist the child with daily activities.
- Assess pain after invasive procedures.
- Review laboratory CD4 counts daily. ✅Administer prescribed medications.
Although assisting with activities, assessing pain, and reviewing CD4 counts are all
important, the priority when caring for a child with HIV is to administer prescribed
medications. Prescribed medications prevent progressive deterioration of the immune
system and provide prophylaxis against opportunistic infections.
The nurse is developing a plan of care for a child with thalassemia. What nursing
interventions would the nurse include? Select all that apply.
- Administer packed RBC transfusions as ordered.
- Administer deferoxamine therapy.
- Administer heparin therapy.
- Offer opioid analgesics.
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