Silvestri Chapter 32 Ed#55c

Silvestri, 3/e, ISBN 1-1460-0052-6 Chapter 032 (edited file)—"Cardiovascular Disorders" 10/14/08, Page 1 of 9, 1 Figure(s), 0 Table(s), 7 Box(es)

32: Cardiovascular Disorders PRACTICE QUESTIONS 1. A nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of congestive heart failure (CHF). The nurse monitors the infant closely for which early sign of CHF? 1. Cough 2. Tachycardia 3. Slow and shallow breathing 4. Pallor Answer: 2 Rationale: The early signs of CHF include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in CHF as a result of mucosal swelling and irritation, but it is not an early sign. Pallor may be noted in the infant with CHF, but is also not an early sign. Test-Taking Strategy: Use the process of elimination and note the key word, early. Think about the physiology and the effects on the heart when fluid overload occurs. These concepts will assist in directing you to option 2. If you had difficulty with this question, review the early signs of CHF in an infant. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders. p. 87. 2. A physician has prescribed oxygen PRN for the child with congestive heart failure (CHF). In which of the following situations does the nurse administer the oxygen to the child? 1. During feeding 2. When the mother is holding the child 3. When changing the child’s diapers 4. When drawing blood for measurement of electrolyte levels Answer: 4 Rationale: Oxygen administration may be ordered for stressful periods, especially during bouts of crying or invasive procedures. Drawing blood is an invasive procedure that would likely cause the child to cry. Test-Taking Strategy: Use the process of elimination. Read the options and recall the situations that would place stress and an increased workload on the heart. This concept should direct you to option 4. Review care of the child with CHF if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia:

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W.B. Saunders. p. 94. 3. An infant with congestive heart failure (CHF) is receiving diuretic therapy and the nurse is closely monitoring the intake and output (I&O). Which is the best method for the nurse to use to monitor the urine output? 1. Inserting a Foley catheter 2. Weighing the diapers 3. Comparing intake with output 4. Measuring the amount of water added to formula Answer: 2 Rationale: The best method to monitor urine output in an infant on 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 Foley catheter drainage is most accurate in determining output, it is not the best method, and places the infant at risk for infection. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they will not provide an indication of urine output. From the remaining options, note the word “best” in the stem of the question. This will direct you to option 2. Review care of the infant receiving diuretic therapy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders. p. 94. 4. A nurse is monitoring the daily weight of an infant with congestive heart failure (CHF). Which of the following alerts the nurse to suspect fluid accumulation and the need to notify the registered nurse? 1. Bradypnea 2. Diaphoresis 3. Decreased blood pressure (BP) 4. A weight gain of 1 pound in 1 day Answer: 4 Rationale: A weight gain of 0.5 kg (1 pound) in 1 day is due to the accumulation of fluid. The nurse should monitor urine output, monitor for evidence of facial or peripheral edema, check the lung sounds, and report the weight gain. Tachypnea and an increased BP would occur with fluid accumulation. Diaphoresis is a sign of CHF but is not specific to fluid accumulation, and usually occurs with exertional activities. Test-Taking Strategy: Use the process of elimination and focus on the issue, fluid accumulation. Note the relationship between “fluid accumulation” in the question and “weight gain” in the correct option. Review the indications of fluid accumulation in an infant with CHF if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection

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Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders. p. 94. 5. A nurse provides home care instructions to the parents of a child with congestive heart failure (CHF) regarding the procedure for the administration of digoxin (Lanoxin). Which statement, if made by a parent, indicates the need for further instruction? 1. “If my child vomits after medication administration, I will repeat the dose.” 2. “I will take my child’s pulse before administering the medication.” 3. “I will not mix the medication with food.” 4. “If more than one dose is missed, I will call the physician.” Answer: 1 Rationale: The parents need to be instructed that if the child vomits after the digoxin is administered, they are not to repeat the dose. Options 2, 3, and 4 are accurate instructions regarding the administration of this medication. Additionally, the parents should be instructed that, if a dose is missed and it is not noticed until 4 hours later, the dose should not be administered. Test-Taking Strategy: Note the key words, need for further instruction. These words indicate a false response question and that you need to select the incorrect client statement. General knowledge regarding digoxin administration will assist in eliminating option 2. Principles related to administering medications to children will assist in eliminating option 3. From the remaining options, select option 1 over option 4 because, if the child vomits, it would be difficult to determine if the medication was also vomited or absorbed by the body. Review home care instructions regarding the administration of digoxin if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 624. 6. A nurse is assigned to care for an infant with a diagnosis of tricuspid atresia. The nurse plans care, knowing that in this disorder: 1. There is no communication from the systemic and pulmonary circulations. 2. Frequent episodes of hypercyanotic spells occur. 3. There is no communication from the right atrium to the right ventricle. 4. A single vessel overrides both ventricles. Answer: 3 Rationale: In tricuspid atresia, there is no communication from the right atrium to the right ventricle. Option 1 describes transposition of the great arteries. Frequent episodes of hypercyanotic spells occur in tetralogy of Fallot. Option 4 describes truncus arteriosus. Test-Taking Strategy: Use the process of elimination. Note the relationship between “tricuspid atresia” and the description in option 3. Recalling that the tricuspid valve is located between the right atrium and the right ventricle will direct you to this option. Review the characteristics of tricuspid atresia if you had difficulty with this question. Level of Cognitive Ability: Comprehension

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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Child Health Reference: Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 1497. 7. Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The mother of the child asks the nurse why the child needs the medication. The nurse tells the mother that the medication: 1. Maintains an adequate hormone level 2. Maintains the position of the great arteries 3. Provides adequate oxygen saturation and maintains cardiac output 4. Prevents hypercyanotic (tet) spells Answer: 3 Rationale: A child with transposition of the great arteries may receive prostaglandin E1 temporarily to increase blood mixing if systemic and pulmonary mixing are inadequate to provide an oxygen saturation of 75% or to maintain cardiac output. Options 1, 2, and 4 are incorrect. Additionally, tet spells occur in tetralogy of Fallot. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation—to answer the question. Option 3 addresses circulation. Review the purpose of this medication in this condition if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 1499. 8. A nurse reviews the record of a child just seen by the physician. The physician has documented a diagnosis of suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? 1. Hyperactivity 2. Exercise intolerance 3. Pallor 4. Gastrointestinal disturbances Answer: 2 Rationale: The child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted, but is not specific to this type of disorder alone. Options 1 and 4 are not related to this disorder. Test-Taking Strategy: Use the process of elimination focusing on the disorder. Options 1 and 4 can be eliminated first because they are not associated with a cardiac disorder. From the remaining options, noting the word “specifically” in the stem of the question will direct you to option 2. Review the manifestations associated with aortic stenosis if you had difficulty with this question. Level of Cognitive Ability: Comprehension

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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 1495. 9. A nurse has reinforced home care instructions to the mother of a child who is being discharged following cardiac surgery. Which statement made by the mother indicates a need for further instructions? 1. “Large crowds of people need to be avoided for at least 2 weeks following surgery.” 2. “I can apply lotion or powder to the incision if it is itchy.” 3. “A balance of rest and exercise is important.” 4. “Activities where the child could fall need to be avoided for 2 to 4 weeks.” Answer: 2 Rationale: The mother should be instructed that lotions and powders should not be applied to the incision site. Options 1, 3, and 4 are accurate instructions regarding home care following cardiac surgery. Test-Taking Strategy: Note the key words, indicates a need for further instructions. These words indicate a false response question and that you need to select the incorrect client statement. Using general principles related to postoperative incisional site care will direct you to option 2. Review home care instructions following cardiac surgery if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders. p. 95. 10. A nurse is reviewing the physician's orders for a child who was just admitted to the hospital with a diagnosis of Kawasaki disease. The nurse expects to note an order for which of the following as part of the treatment plan? 1. Morphine sulfate 2. Immune globulin 3. Heparin infusion 4. Digoxin (Lanoxin) Answer: 2 Rationale: Intravenous immune globulin (IVIG) is administered to the child with Kawasaki disease to decrease the incidence of coronary artery lesions and aneurysms and to decrease fever and inflammation. Options 1, 3, and 4 are not components of the treatment plan for this disease. Test-Taking Strategy: Use the process of elimination. Remember that the pharmacological treatment for this disease is acetylsalicylic acid (aspirin) and IVIG. If you had difficulty with this question, review the treatment plan for the child with Kawasaki disease. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning

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Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 629. 11. A nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. On admission, the nurse prepares to ask the mother which question to elicit information specific to the development of RF? 1. “Did the child have a sore throat or an unexplained fever within the last 2 months?” 2. “Has the child had any nausea or vomiting?” 3. “Has the child complained of headaches?” 4. “Has the child complained of back pain?” Answer: 1 Rationale: 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 if the child has had a sore throat or an unexplained fever within the past 2 months. Options 2, 3, and 4 are unrelated RF. Test-Taking Strategy: Use the process of elimination. Note the similarity between rheumatic “fever” in the question and the word “fever” in the correct option. If you had difficulty with this question, review the etiology related to RF. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 626. 12. Acetylsalicylic acid (Aspirin) is prescribed for the child with rheumatic fever. The nurse would question this order if the child had documented evidence of which of the following? 1. A viral infection 2. Joint pain 3. Facial edema 4. Arthralgia Answer: 1 Rationale: Anti-inflammatory agents, including aspirin, may be prescribed for the child with RF. Aspirin should not be given to a child who has chickenpox or other viral infections such as the flu. Options 2 and 4 are clinical manifestations of RF. Facial edema may be associated with the development of a cardiac complication. Test-Taking Strategy: Use the process of elimination. Options 2 and 4 can be eliminated because they are similar. Recalling that facial edema may indicate a cardiac complication will assist in eliminating this option. Review the contraindications related to the use of aspirin if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Child Health References: Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.).

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Philadelphia: W.B. Saunders, p. 626. Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders. p. 298. 13. A nurse is caring for a child with a suspected diagnosis of rheumatic fever (RF). The nurse reviews the laboratory results, knowing that which laboratory study would assist in confirming the diagnosis of RF? 1. White blood cell count 2. Red blood cell count 3. Immunoglobulin 4. Antistreptolysin O titer Answer: 4 Rationale: A diagnosis of RF is confirmed by the presence of two major manifestations or one major and two minor manifestations from the Jones criteria. Additionally, evidence of a recent streptococcal infection is confirmed by a positive antistreptolysin O titer, streptozyme, or an antiDNase B assay. Options 1, 2, and 3 will not assist in confirming the diagnosis of RF. Test-Taking Strategy: Use the process of elimination. Recalling that RF is characteristically associated with streptococcal infection will direct you to option 4. If you had difficulty with this question, review the RF. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders. p. 297. 14. A nurse is caring for a child with a diagnosis of Kawasaki disease. The mother of the child asks the nurse about the disorder. The nurse tells the mother that: 1. It is an acquired cell-mediated immunodeficiency disorder. 2. It is an inflammatory autoimmune disease that affects the connective tissue of the heart, joints, and subcutaneous tissues. 3. It is a chronic multisystem autoimmune disease characterized by the inflammation of connective tissue. 4. Is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause. Answer: 4 Rationale: Kawasaki disease, also called mucocutaneous lymph node syndrome, is a febrile generalized vasculitis of unknown etiology. Option 1 describes human immunodeficiency virus (HIV) infection. Option 2 describes rheumatic fever. Option 3 describes systemic lupus erythematosus. Test-Taking Strategy: Knowledge regarding the description of Kawasaki disease is required to answer this question. Remember, Kawasaki disease is a febrile generalized vasculitis of unknown etiology. Review the characteristics of this disorder if you are unfamiliar with it. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation

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Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 628. 15. A nurse assists in admitting a child with a diagnosis of acute stage Kawasaki disease. On data collection, the nurse expects to note which clinical manifestation of the acute stage of the disease? 1. Conjunctival hyperemia 2. Cracked lips 3. Desquamation of the skin 4. A normal appearance Answer: 1 Rationale: In the acute stage, the child presents with fever, conjunctival hyperemia, a red throat, swollen hands, a rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may be present. Test-Taking Strategy: Use the process of elimination. Noting the key words, acute stage, in the question will assist in directing you to option 1. Review the clinical manifestations associated with each stage of Kawasaki disease if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 628. 16. A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic, and the nurse recognizes that the infant is experiencing a hypercyanotic spell. Select the interventions that the nurse takes. ____Place the infant in a prone position. ____Notify the registered nurse. ____Prepare to administer 100% oxygen by face mask. ____Call a code blue. ____Prepare to administer morphine sulfate. Answers: Notify the registered nurse. Prepare to administer 100% oxygen by face mask. Prepare to administer morphine sulfate. Rationale: Hypercyanotic episodes often occur in infants with tetralogy of Fallot and may occur in infants whose heart defect includes obstruction to pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is then notified, who will then contact the physician. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return, so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue

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unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed. Test-Taking Strategy: Focus on the infant’s diagnosis. Review the nursing interventions when a hypercyanotic episode occurs in an infant if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 1488.