ch 41 cardiac disorders

Question 1

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

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?

Answer 2

administer the next dose as ordered in 12 hours

Question 3

the nurse is caring from an infant with suspected patent ductus arteriosus. which assessment finding would the nurse identify as helping to confirm this suspicion?

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 finding would the nurse most likely expect to assess if the child had transposition of the great vessels?

Answer 4

significant cyanosis without presence of a murmur

Question 5

the nurse is assessing a child with suspected infective endocarditis. which assessment finding would the nurse interpret as a sign of extra cardiac emboli?

Answer 5

roth spots

Question 6

when conducting a physical examination of a child with suspected kawasaki disease, which finding would the nurse expect to assess?

Answer 6

strawberry tongue

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 assessment finding?

Answer 7

Jerky movements of the face and upper extremities

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, how would the nurse document this murmur?

Answer 8

loud without a thrill

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 statement by the mother indicates a need for further teaching?

Answer 9

“ i need to feed him every hour to make sure he eats enough”

Question 10

the nurse is caring for an infant girl with a suspected cardiovascular disorder. which statement by the mother would warrant further investigation?

Answer 10

“the baby seems more comfortable over my shoulder”

Question 11

auscultation of a child’s heart reveals a loud murmur with a pre cordial thrill. The nurse documents this as which grade?

Answer 11

Grade IV

Question 12

after assessing a child’s blood pressure, the nurse determines the pulse pressure and finds that is is narrowed. What would the nurse identify as associated with this finding?

Answer 12

aortic stenosis

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?

Answer 13

He should avoid taking a bath for about 3 days, but he can shower

Question 14

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

Answer 14

Indomethacin

Question 15

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

Answer 15

maintenance of a strict bed rest

Question 16

after teaching a class about the hemodynamic characteristics of congenital heart disease, the instructor determines that the teaching has been successful when the class identifies which defect as an example of a disorder involving increased pulmonary blood flow?

Answer 16

arterial septal defect

Question 17

a 7 year old child with a family history of cardiovascular disease is being screened for hyperlipidemia. when reviewing the child’s lab results, which total cholesterol level would be of significant concern?

Answer 17

210 mg/dL (5.44 mmol/L)

Question 18

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

Answer 18

“a special wand that picks up sound is used to check your heart”

Question 19

the nurse is reviewing the medical record of a child with infective endocarditis. What would the nurse expect to find? select all that apply.

Answer 19

-microscopic hematuria with urinalysis
-electrocardiography with prolonged PR interval
-petechiae on palpebral conjunctiva

Question 20

a child with heart failure is receiving supplemental oxygen. The nurse understands that in addition to improving oxygen saturation, this intervention also has what effect?

Answer 20

cause vasodilation

Question 21

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 healthcare provider if the infant’s apical pulse rate was:

Answer 21

80 beats per minute (anything under 90 beats per min)

Question 22

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?

Answer 22

“I should eat plenty of fresh fruits and vegetables”

Question 23

A child is diagnosed with Kawasaki disease and is in the acute phase of the disorder. What would the nurse expect the provider to prescribe? select all that apply.

Answer 23

-Intravenous immunoglobulin
-Asprin

Question 24

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?

Answer 24

“Breast milk may help to boost her immune system, so you can continue to use it”

Question 25

during a follow-up visit, the parents of a 5 month old infant diagnosed with congenital heart disease tells 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?

Answer 25

interrupted family process related to demands of caring for the ill child

Question 26

a child with suspected dyslipidemia undergoes lab testing. The nurse is reviewing the results. Which finding would the nurse interpret as supporting the diagnosis? select all that apply.

Answer 26

-total cholesterol level 220 mg/dL (5.70 mmol/L) -LDL level of 140 mg/dL (3.63 mmol/L) hyperlipidemia: TC > 200, LDL >130

Question 27

the mother of a 4 week old infant is tearful. She reports the healthcare provider has told her that her son has a small atrial septal defect. She reports she is worried and asks the nurse more about the condition. Which statement by the parents best indicates an understanding of the nurse’s teaching?

Answer 27

“most of the time this condition spontaneously resolves”

Question 28

the nurse is caring for a child that just returned from a coronary arteriogram in which the catheter was placed through the left femoral artery. which nursing action demonstrate knowledge of the procedure? select all that apply.

Answer 28

-the nurse assesses the dorsalis pedis pulse in the left foot -the nurse assesses the puncture site frequently -the nurse tells the parents that the healthcare provider will discuss the results of the procedure with them

Question 29

the nurse is caring for a newborn diagnosed with an atrial septal defect. The parents voice concern and state, “I can’t believe this is happening. Will our child be okay?” What is the nurse’s best response?

Answer 29

“while each case is different, the majority of these defects correct on their own. Let’s see what the tests show, then speak with the healthcare provider