Cardiovascular Disorders

Question 1

The nurse is monitoring an infant w/congenital heart disease closely for signs of HF. The nurse should assess the infant for which early sign of HF?

1. Pallor
2. Cough
3. Tachycardia
4. Slow and shallow breathing

Answer 1

3. Tachycardia

Rationale: Hf is the inability of the heart to pump a sufficient amount of blood to meet the O2 & metabolic needs of the body. Early signs of HF include tachycardia, profuse scalp sweating, fatigue/irritability, sudden weight gain & respiratory distress.

Question 2

The nurse reviews the lab results for a child with suspected rheumatic fever, knowing that which lab study would assist in confirming the diagnosis?

1. Immunoglobulin
2. RBC count
3. WBC count
4. Anti-streptolysin O titer

Answer 2

4. Anti-streptolysin O titer

Rationale: RF is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin, blood vessels & CNS. Diagnosis is confirmed by the presence of 2 major manifestations or 1 major manifestation & 2 minor from the Jones criteria. Evidence of a recent streptococcal infection is confirmed by a positive anti-streptolysin O titer, Streptozyme assay, or anti DNase B assay.

Question 3

On assessment of a child admitted w/a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease?

1. Cracked lips
2. Normal appearance
3. Conjunctival hyperemia
4. Desquamation of skin

Answer 3

3. Conjunctival hyperemia

Rationale: Kawasaki disease (AKA: mucocutaneous lymph node syndrome) is an acute systemic inflammatory illness. In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash & enlargement of cervical lymph nodes. In the subacute stage, cracing lips & fissures, desquamation of skin on the tips of the fingers & toes, joint pain, cardiac manifestations & thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may be present.

Question 4

The nurse provides home care instructions to the parents of a child w/HF regarding the procedure for administration of Digoxin (Lanoxin). Which statement made by the parent indicates the need for further instruction?

1. I will not mix the medication with food.
2. I will take my child’s pulse before administering.
3. If more than one dose is missed, I will call the HCP.
4. If my child vomits after medication admin, I will repeat the dose.

Answer 4

4. If my child vomits after medication admin, I will repeat the dose.

Rationale: Digoxin is a cardiac glycoside. The parents need to be instructed that if the child vomits after it’s administered, they are not to repeat the dose. The parents should also be instructed that if a dose is missed & is not identified until 4 hours later, the dose should not be administered.

Question 5

The nurse is closely monitoring the intake & output of an infant w/HF who’s receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output?

1. Weighing the diapers
2. Inserting a foley catheter
3. Comparing intake with output
4. Measuring the amount of water added to formula

Answer 5

1. Weighing the diapers

Rationale: HF is the inability of the heart to pump a sufficient amount of blood to meet the O₂& metabolic needs of the body. Comparing intake with output would not provide an accurate measure of urine output. Measuring the amount of water added to formula is unrelated to output.

Question 6

The clinic nurse reviews the record of a child just seen by an HCP & diagnosed w/suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specificaly found in this disorder?

1. Pallor
2. Hyperactivity
3. Exercise intolerance
4. GI disturbances

Answer 6

3. Exercise intolerance

Rationale: aortic stenosis is a narrowing or stricture of the aortic valve, causing resistance to blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy & pulmonary vascular congestion. A child w/aortic stenosis shows signs of exercise intolerance, chest pain & dizziness when standing for long periods. Pallor may be noted, but is not specific to this type of disorder alone.

Question 7

The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement by the parents indicates a need for further teaching?

1. A balance of rest and exercise is important
2. I can apply lotion or powder to the incision if it is itchy
3. Activities in which my child could fall need to be avoided for 2-4 weeks
4. Large crowds of people need to be avoided for at least 2 weeks after surgery

Answer 7

2. I can apply lotion or powder to the incision if it is itchy

Rationale: The mother should be instructed that lotions & powders should not be applied to the incision site after cardiac surgery. They can irritate the surrounding skin, which could lead to skin breakdown & subsequent infection of the incision site.