Assessment
The nurse is collecting data on a child with a diagnosis of rheumatic fever. Which question should the nurse initially ask the mother of the child?
1.
"Has the child been vomiting?"
2.
"Has the child had any diarrhea?"
3.
"Does the child complain of chest pain and numbness in the right arm?"
4.
"Has the child complained of a sore throat within the past few months?"
ANS: 4
Rheumatic fever (RF) characteristically presents 2 to 6 weeks following an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child or any family members have had a sore throat or unexplained fever within the past 2 months. The remaining options are unrelated to RF.
A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant?
During sleep
2.
When changing the infant's diapers
3.
When the mother is holding the infant
4.
When drawing blood for electrolyte level testing
ANSWER: 4.
Heart failure (HF) is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. Crying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful periods, especially during bouts of crying or invasive procedures. Options 1, 2, and 3 are not likely to produce crying in the infant.
A nurse is assigned to care for an infant with an unrepaired tetralogy of Fallot. What should the nurse do first when the baby is crying and becomes severely cyanotic?
a.
Place the infant in a knee-chest position.
b.
Administer oxygen.
c.
Administer morphine sulfate.
d.
Notify the physician.
Ans: A
NS: A
Placing the infant in a knee-chest position will decrease venous return so that smaller amounts of highly saturated blood reach the heart. Administering oxygen is indicated after placing the infant in a knee-chest position. Administering morphine sulfate calms the infant. It is indicated after the infant has been placed in a knee-chest position. The physician should be notified after the infant has been placed in a knee-chest position.
Select all the components of Tetralogy of Fallot
a. Overriding aorta
b. Atrial septal defect
c. left ventricular hypertrophy
d. Ventricular septal defect
e. Aortic stenosis
Answer: A, D.
The 4 components of Tetralogy of Fallot are
1. Overriding Aorta
2. Pulmonary stenosis (not aortic stenosis)
3. Ventricular septal defect (not atrial septal defect)
4. Right ventricular hypertrophy (not left ventricular hypertrophy)
Weak peripheral pulses can indicate:
1. A weak heart.
2. Poor cardiac output.
3. Hypertension.
4. Patent ductus arteriosus.
ANS: 2
Feedback1.The heart may be weak, but does not indicate that the pulses will be weak.2.A lower amount of output does not allow for peripheral pulses to be easily felt.3.If the patient has hypertension, the pulses may be bounding.4.Patent ductus arteriosus may have bounding pulses.
a. Kawasaki Disease
b. Heart Failure
c. Rheumatic Fever
d. Atherosclerosis
Assessments of early signs of HR is
1. tachycardia, espeically during rest and slight exertion
2. tachypnea
3. profuse scalp diaphoresis, especially infants
5. fatigue and irritability
6. sudden wt gain
7. respiratory distress
Nursing care for the child in congestive heart failure includes which action?
a.
Counting the number of saturated diapers
b.
Putting the infant in the Trendelenburg position
c.
Removing oxygen while the infant is crying
d.
Organizing care to provide rest periods
ANS: D
Nursing care should be planned to allow for periods of undisturbed rest. Diapers must be weighed for an accurate record of output. The head of the bed should be raised to decrease the work of breathing. Oxygen should be administered during stressful periods such as when the child is crying.
A child just arrived from a cardiac surgery, 4 hours later the BP has dropped from 120/60 to 80/40, what would be your best initial action after assessment that the child is bleeding.
1. Place the child in trendelenburg position then call for help
2. Give IV fluids then call for help
3. Apply pressure then call for help
4. Pray for a miracle then call for help
3. Apply pressure
What kind of signs and symptoms might you see in a child that results SPECIFICALLY from failing of the RIGHT side of the heart to pump efficiently. (Select All the Apply)
a. Ascites
b. cough
c. dyspnea
e. Oliguria
f. peripheral edema
Answer: A, E, F
Left Sided HF includes
- Crackles and wheezes
- cough
- dyspnea
- grunting (infants)
- head bobbing (infants_
- Nasal flaring
- Orthopnea
- Periods of cyanosis
- Retractions
- Tachypnea
For Right Sided HR
- Ascites
- Hepatosplenomegaly
- Jugular Ven distention
- Oliguria
- Peripheral edema, especially dependent edema, and periorbital edema
- wt gain
A 7-year-old child is discharged following a cardiac catheterization yesterday. The nurse should instruct the mother to:
1. Allow the child to take a tub bath today.
2. Allow the child to resume normal physical activities, including sports.
3. Limit diet within the first few days to prevent straining to stool.
4. Observe for signs and symptoms of infection for the first few days.
ANS:
ANS: 4
Feedback1.The child can take showers, not baths, for the first several days.2.The child should not lift anything heavy and should not resume physical activity for two weeks.3.There is no limit on the diet of the child.4.The child should be monitored for signs and symptoms of infection.
A nurse is caring for a child admitted to the hospital with Kawasaki disease. Which cardiac complication of Kawasaki disease should the nurse monitor for?
a.
Cardiac valvular disease
b.
Cardiomyopathy
c.
Coronary aneurysm
d.
Rheumatic fever
ANS: C
Coronary aneurysm formation begins early in the second phase of Kawasaki syndrome. Coronary artery aneurysms are seen in 20% of children with untreated Kawasaki disease. Cardiac valvular disease can occur in rheumatic fever. Cardiomyopathies are diseases of the heart muscle, which can occur as a result of congenital heart disease, coronary artery disease, or other systemic disease. Rheumatic fever is not a complication of Kawasaki syndrome.
The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item?
1.
Bananas
2.
Broccoli
3.
Antacids
4.
Cantaloupe
ANS: 3
The sodium level can increase with the use of several types of products, including toothpaste and mouthwash; over-the-counter medications such as analgesics, antacids, laxatives, and sedatives; and softened water and mineral water. Clients are instructed to read labels for sodium content. Water that is bottled, distilled, deionized, or demineralized may be used for drinking and cooking. Fresh fruits and vegetables are low in sodium.
After a patient returns from cardiac catheterization, the nurse assesses that the pulse distal to the catheter insertion site is weaker. The nurse should:
a. elevate the affected extremity.
b. record the data on the nurse’s notes.
c. notify the physician of the observation.
d. pply warm compresses to the insertion site.
ANSWER: b,
Elevation is not necessary; the extremity is kept straight. The pulse distal to the catheter insertion site may be weaker for the first few hours after catheterization. It should gradually increase in strength. Because a weaker pulse is an expected finding, the nurse should document this and continue to monitor. The insertion site is kept dry
Many congenital heart defects may cause decreased cardiac output, what are the signs and symptoms you might see in child. (Select All that apply)
a. Increased peripheral pulses
b. Exercise intolerance
c. Tachycardia
d. Hypotension
e. Feeding difficulties
f. Warm, flushed extremeties
Signs and Symptoms of Decreased of CO are
- Decreased peripheral pulses (NOT increased peripheral pulses due to lack of volume being pumped out per minute)
- Exercise intolerance
- Feeding difficulties
- hypotension
- Irritability, resltessness, lethargy
- Oliguria
- Pale, cool extremities (Not warm, flushed extremities because blood is directed away from the extremities in low CO)
- Tachycardia
A child with congenital heart disease is more prone to develop which complication?
1. Urinary disturbances
2. Bleeding tendencies
3. Repeated abdominal distention
4. Repeated respiratory infections
ANS: 4
Feedback1.Congenital heart disease does not cause urinary disturbances.2.Congenital heart disease does not result in bleeding tendencies.3.Congenital heart disease does not result in repeated abdominal distention.4.Congenital heart disease does predispose the child to repeated respiratory infections due to pulmonary congestion.
The nurse reviews the laboratory results for a child with rheumatic fever and would expect to note which findings?
a. presence of Aschoff's bodies
b. Decreased erythrocyte sedimentation rate
c. Presence of Group B streptococcus (GBS) infection
d. Decreased antistreptolysin O titer
ANS: A.
Rheumatic fever usually develops after a group A beta-hemolytic streptococcal infection, particularly pharyngitis. Initial diagnosis is made by noting the presence of Aschoff's bodies, or hemorrhagic bullous lesions, in the heart, joints, skin, and central nervous system; an elevated C-reactive protein level; an elevated antistreptolysin O titer; and an elevated erythrocyte sedimentation rate. Reed-Sternberg cells are found in Hodgkin's disease
The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output?
1.
Weighing the diapers
2.
Inserting a urinary catheter
3.
Comparing intake with output
4.
Measuring the amount of water added to formula
ANSER: 1
Heart failure is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. The most appropriate method for assessing urine output in an infant receiving diuretic therapy is to weigh the diapers. Comparing intake with output would not provide an accurate measure of urine output. Measuring the amount of water added to formula is unrelated to the amount of output. Although urinary catheter drainage is most accurate in determining output, it is not the most appropriate method in an infant and places the infant at risk for infection.
A young child with tetralogy of Fallot may assume a posturing position as a compensatory mechanism. The position automatically assumed by the child is:
a. low Fowler’s.
b prone.
c supine.
d squatting.
ANS: D
Low Fowler’s would assist with respiratory issues but would not assist with the need for cardiac compensation. Prone does not offer any advantage to the child. Supine does not offer any advantage to the child. The squatting or knee-chest position decreases the amount of blood returning to the heart and allows the child time to compensate.
a. Atrial Septal defect
b. ventricular septal defect
c. patent ductus arteriosus
d. arioventricular canal defect
f. Coarctation of Aorta
e. Aortic stenosis
ANSWER: A, B, C, D
Increased pulmonary blood are:
Atrial septal defect
Ventricular septal defect
PDA
Arioventricular canal defect
Decreased pulmonary blood flow are:
- Tetralogy of Fallot
Obstructive defects are
- coarctation of the aorta
- aortic stenosis
The onset of symptoms occurs around 20 days after streptococcus throat infection or scarlet fever.
2. The child lives in the most common area of the western United States.
3. The disease produces lesions in the mouth and oropharynx.
4. The disease results in damage to the peripheral sensory nerves.
ANS: 1
NS: 1
Feedback1.This is the normal course of this disease.2.Most cases occur in the northeastern part of the United States.3.The disease produces polyarthritis, carditis, subcu nodules, and a low-grade fever.4.The disease produces polyarthritis, carditis, St. Vitus Dance, and a low-grade fever.
What kind of signs and symptoms might you see in a child that results SPECIFICALLY from failing of the LEFT side of the heart to pump efficiently. (Select All the Apply)
a. Crackles
b. cough
c. dyspnea
e. nasal flaring
f. peripheral edema
Answer: A, B, C, D, E,
Left Sided HF includes
- Crackles and wheezes
- cough
- dyspnea
- grunting (infants)
- head bobbing (infants_
- Nasal flaring
- Orthopnea
- Periods of cyanosis
- Retractions
- Tachypnea
For Right Sided HR
- Ascites
- Hepatosplenomegaly
- Jugular Ven distention
- Oliguria
- Peripheral edema, especially dependent edema, and periorbital edema
- wt gain
Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The mother of the child is a registered nurse and asks the nurse why the child needs the medication. What is the most appropriate response to the mother about the action of the medication?
1.
Prevents blue (tet) spells
2.
Maintains adequate cardiac output
3.
Maintains an adequate hormonal level
4.
Maintains the position of the great arteries
ANS: 2.
Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The mother of the child is a registered nurse and asks the nurse why the child needs the medication. What is the most appropriate response to the mother about the action of the medication?
What should you do in a child having a hypercyanotic spell (select all)
a. Place infant in a knee child position
b. Give 65% O2
c. Give morphine
d. Start an IV access
e. Document actions taken and re-assess infants response to therapy
ANSWER: A, C, D, E.
All other questions are correct but B. You would give 100% oxygen instead of 65%
What might you teach to parents who have a child with kawasaki disease (sellect all)
1. Salicylates such as acetylsalicyluc acid (aspirin) may be prescribed
2. Follow up care is essential to recovery
3. The child should avoid contact sports, if age appropriate, if taking aspirin or anticoagulants
4. Record temperature (because fever is expected) until the child has been afebrile for several days
- Follow up care is essential to recovery
- signs and symptoms of kawasaki disease
- Recording the temp
- Notify the PCP if temp is 101 F or 38.3 C
- Aspirin may be given, so signs of aspirin toxicity has to be taught.
- Signs and symptoms of bleeding
- Signs and symptoms of cardiac complications
- Child should avoid contact sports
In educating an adolescent and his/her caregivers on the modifiable risk factors related to the hypertension, the nurse would include information related to: (Select all that apply.)
1. Age.
2. Race or ethnicity.
3. Hyperlipidemia.
4. Exercise levels.
5. Weight management.
ANS: 3, 4, 5
Feedback1.Age is not a modifiable risk factor.2.Race and ethnicity are not modifiable risk factors.3.Hyperlipidemia through diet education is a modifiable risk factor.4.Exercise levels are modifiable risk factors that can reduce hypertension.5.Weight management is a modifiable risk factor that can reduce hypertension.