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Nurs 232 Exam 4: Questions With Expert Solutions (Guaranteed Pass)
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Nurs 232 Exam 4: Questions With Expert Solutions (Guaranteed Pass)
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Nurs 232 Exam 4: Questions With Expert Solutions(Guaranteed Pass)
Which of the following are clinical manifestations of HF? (select all apply)
a) hepatomegaly and ascites
b) bradypnea and cyanotic
c) nasal flaring and retractions
d) restlessness and irritability
e) fluid retention and edema Right Ans - a) hepatomegaly and ascites
c) nasal flaring and retractions
d) restlessness and irritability
e) fluid retention and edema
*tachypnea, pallor, tachycardia, wheezing, crackles, grunting, ascites, weight
gain from fluid, or poor weight gain, poor feeding w diaphoresis, weak pulses,
prolonged cap refill, cool extremities, oliguria, restlessness, irritability
Surgical repair for patent ductus arteriosus (PDA) is done to prevent the
complication of
a) pulmonary infection.
b) right-to-left shunt of blood.
c) decreased workload on left side of heart.
d) increased pulmonary vascular congestion. Right Ans - d) increased
pulmonary vascular congestion
*A PDA allows blood to flow from the aorta (high pressure) to the pulmonary
artery (low pressure).
*A PDA involves a left-to-right shunt of blood, so if the PDA stays open it can
increase pulmonary vascular congestion
*pulmonary infection may occur, but it is not the priority complication
A cardiac assessment is required to determine if a child's physical symptoms
are related to possible heart disease. The nurse is proceeding to auscultation
techniques. When observing the nursing student, which action would indicate
that additional training was required?
a) Documentation of heart sounds in reference to anatomical location.
b) Determination that there is no evidence of carotid bruits.
c) Calculation of heart rate.
,d) Ascertaining whether there is evidence of splenic enlargement. Right
Ans - d) Ascertaining whether there is evidence of splenic enlargement.
*Evidence of splenic enlargement requires palpation
What should nurses stress when counseling parents regarding the home care
of the child with a cardiac defect before corrective surgery?
a) The importance of reducing caloric intake to decrease cardiac demands
b) The importance of relaxing discipline and limit setting to prevent crying
c) The need to be extremely concerned about cyanotic spells
d) The desirability of promoting normalcy within the limits of the child's
condition Right Ans - d) The desirability of promoting normalcy within the
limits of the child's condition
*child needs to have social interactions, discipline, and appropriate limit
setting. Parents need to be encouraged to promote as normal a life as possible
for their child.
*child needs increased caloric intake after cardiac surgery.
*cyanotic spells will occur in children with some defects, the parents need to
be taught how to assess for and manage them appropriately, thereby
decreasing their anxiety and concern.
A young child with tetralogy of Fallot (TOF) may assume a posturing position
as a compensatory mechanism. The position automatically assumed by the
child is
a) the low Fowler position.
b) the prone position.
c) the supine position.
d) the squatting position. Right Ans - d) the squatting position.
*squatting or knee-chest position increases the return of blood flow to the
heart for oxygenation in a child with a defect that consists of decreased
pulmonary blood flow
What is an important nursing responsibility when a dysrhythmia is
suspected?
a) Order an immediate electrocardiogram.
b) Count the radial pulse every 1 minute for five times.
c) Count the apical pulse for 1 full minute, and compare the rate with the
radial pulse rate.
,d) Have someone else take the radial pulse simultaneously with the apical
pulse. Right Ans - c) Count the apical pulse for 1 full min and compare the
rate with the radial pulse rate.
*If a dysrhythmia is occurring, the radial pulse rate may be lower than the
apical pulse rate.
What is considered a mixed cardiac defect?
a) Pulmonic stenosis (PS)
b) Atrial septal defect (ASD)
c) Patent ductus arteriosus (PDA)
d) Transposition of the great arteries (TGA) Right Ans - d) Transposition of
the great arteries
*allows the mixing of both oxygenated and unoxygenated blood in the heart.
*PS is an obstructive defect
*ASD and PDA increased pulmonary blood flow
After a patient returns from cardiac catheterization, the nurse notes that the
pulse distal to the catheter insertion site is weaker (+1). The most appropriate
nursing intervention is to
a) elevate the affected extremity.
b) document the findings and continue to monitor.
c) notify the health care provider of the finding.
d) apply warm compresses to the insertion site. Right Ans - b) document
the findings and continue to monitor.
*Weaker distal pulse is expected for the first few hours after catheterization. It
should gradually increase in strength.
*The extremity is kept straight and immobile, but elevation is not necessary.
*The insertion site is kept dry. Warm compresses would increase the risk of
bleeding from the insertion
Congenital heart defects have traditionally been divided into acyanotic or
cyanotic defects. Based on the nurse's knowledge of congenital heart defects,
this system in clinical practice is
a) helpful, because it explains the hemodynamics involved.
b) helpful, because children with cyanotic defects are easily identified.
c) problematic, because cyanosis is rarely present in children.
, d) problematic, because children with acyanotic heart defects may develop
cyanosis. Right Ans - d) problematic, because children with acyanotic heart
defects may develop cyanosis.
*does not reflect the blood flow within the heart. Cardiac defects are best
described by using the actual pathophysiologic process and mechanism.
Cyanosis is present when children have defects where there is mixing of
oxygenated blood with unoxygenated blood.
Nursing care of the infant and child with congestive heart failure includes
a) force fluids appropriate to age.
b) monitor respirations during active periods.
c) organize activities to allow for uninterrupted sleep.
d) give larger feedings less often to conserve energy. Right Ans - c)
organize activities to allow for uninterrupted sleep.
*needs to be well rested before feeding and their needs should be met to
minimize crying. The nurse must organize care to decrease energy
expenditure.
*pts w CHF have an excess of fluid, so forcing fluids is contraindicated.
*Monitoring of VS is appropriate, but minimizing energy expenditure is a
priority.
*often cannot tolerate larger feedings; small, frequent feedings should be
given
A physician suspects that a child may have congenital cardiac disease. Which
noninvasive diagnostic procedure would help to confirm the possibility of
heart disease?
a) EKG
b) Echocardiogram
c) Chest x-ray
d) Pulse oximetry Right Ans - b) Echocardiogram
* used to identify either a cardiac anomaly or evidence of heart disease.
*EKG provides evidence of electrical system conduction.
*Pulse oximetry provides information relative to perfusion.
*chest x-ray focuses on lungs and airway exchange, it may not be sensitive and
specific to determine cardiac pathology.
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