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An infant who has Tetralogy of Fallot and is easily fatigued when eating
A nurse is caring for an infant who has Tetralogy of Fallot and notes that the infant is easily fatigued when eating. Which defect is not present in this cardiac congenital malformation?
- A. Overriding aorta
- B. Pulmonary stenosis
- C. Left ventricular hypertrophy
- D. Ventricular septal defect
Correct Answer: C
Rationale: The correct answer is C: Left ventricular hypertrophy is not present in Tetralogy of Fallot. In Tetralogy of Fallot, the four main defects are pulmonary stenosis, overriding aorta, ventricular septal defect, and right ventricular hypertrophy. Left ventricular hypertrophy is not part of the condition. The infant's fatigue during feeding is likely due to decreased oxygen levels in the blood caused by the pulmonary stenosis and right-to-left shunting at the ventricular septal defect. Choices A, B, and D are all components of Tetralogy of Fallot, making them incorrect options.
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A school-age child who has cystic fibrosis
A nurse is reinforcing teaching with the parents of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make?
- A. Your child's diet should be high in carbohydrates & proteins with no restriction of fats.
- B. Limit your child's intake of sodium to avoid complications.
- C. A pigeon-shaped chest might become evident as the disease progresses.
- D. Administer a bronchodilator to the child after chest percussion therapy.
Correct Answer: C
Rationale: The correct answer is C: A pigeon-shaped chest might become evident as the disease progresses. In cystic fibrosis, the chest may appear pigeon-shaped due to the abnormal growth of the ribs and sternum. This is caused by chronic respiratory issues and increased work of breathing. It is important for the nurse to educate the parents about this potential physical manifestation of the disease so they can monitor their child's condition closely.
Incorrect choices:
A: Your child's diet should be high in carbohydrates & proteins with no restriction of fats - This is incorrect as children with cystic fibrosis often require a high-calorie, high-fat diet to meet their increased energy needs.
B: Limit your child's intake of sodium to avoid complications - While monitoring sodium intake can be important for some conditions, it is not a primary concern in cystic fibrosis.
D: Administer a bronchodilator to the child after chest percussion therapy - While bronchodilators may be used in cystic fib
A 9-year-old child who has acute rheumatic fever
A nurse is assisting with the admission of a 9-year-old child who has acute rheumatic fever. When obtaining the client's history, it is appropriate for the nurse to ask the parent which of the following questions?
- A. Has your son had a sore throat recently?
- B. Was your son born with this cardiac defect?
- C. Are you aware that your son will have to be in isolation?
- D. Has your child had any injuries recently?
Correct Answer: A
Rationale: Rationale: A sore throat can be a symptom of acute rheumatic fever, which is important for the nurse to assess. This can help in diagnosing the condition and planning appropriate care. Asking about a recent sore throat is relevant to the child's current health status and can guide further assessment and treatment.
Summary:
B: This question is not relevant to acute rheumatic fever.
C: Isolation is not necessary for acute rheumatic fever, so this question is not appropriate.
D: Recent injuries are not directly related to acute rheumatic fever and are not relevant to the child's current condition.
A toddler receiving ear drops
While administering ear drops to a toddler, a nurse by pulls the auricle down and back. The mother asks, 'Why are you pulling the ear that way?' Which of the following responses should the nurse make?
- A. When I use this technique the medication will not run out of the ear.
- B. This opens the ear canal, allowing medication to reach the inner ear region.
- C. This is the safest and easiest way to administer this medication.
- D. When I use the technique, your child experiences less pain.
Correct Answer: B
Rationale: The correct answer is B: This opens the ear canal, allowing medication to reach the inner ear region. By pulling the auricle down and back, the nurse straightens the ear canal in toddlers, making it easier for the ear drops to reach the inner ear where they are most effective. This technique helps ensure that the medication is properly administered and absorbed.
Incorrect Answers:
A: When I use this technique the medication will not run out of the ear - This is incorrect because the aim of pulling the ear is not to prevent medication from running out but to facilitate its entry.
C: This is the safest and easiest way to administer this medication - This is incorrect as the safety and ease of administration are not the primary reasons for pulling the ear in this context.
D: When I use the technique, your child experiences less pain - This is incorrect as the main purpose of pulling the ear is not to reduce pain but to ensure effective delivery of the medication to the inner ear.
A hospitalized 2-year-old child who has a tantrum when a parent leaves
A nurse is caring for a hospitalized 2-year-old child who has a tantrum when a parent leaves. Which of the following actions should the nurse take?
- A. Give the child a stuffed animal.
- B. Inform the child that her parent will be back in 2 hr.
- C. Call the parent to return to the child's room.
- D. Leave the child alone in the room for 5 min.
Correct Answer: A
Rationale: The correct answer is A: Give the child a stuffed animal. Offering the child a stuffed animal can provide comfort and a sense of security, helping to calm the child during the parent's absence. This action promotes emotional support and may help to reduce the child's anxiety.
Other choices are incorrect:
B: Informing the child about the parent's return time may not effectively address the immediate emotional distress.
C: Calling the parent back may not be feasible or necessary for every instance of separation anxiety.
D: Leaving the child alone can exacerbate feelings of fear and abandonment, potentially escalating the tantrum.
An infant who has coarctation of the aorta
A nurse is collecting data from an infant who has coarctation of the aorta. Which of the following manifestations should the nurse expect?
- A. Machine-like murmur
- B. Severe cyanosis
- C. Decreased blood pressure in the legs
- D. Pulmonary edema
Correct Answer: C
Rationale: The correct answer is C: Decreased blood pressure in the legs. Coarctation of the aorta causes narrowing of the aorta, leading to decreased blood flow to the lower body. This results in decreased blood pressure in the legs due to reduced perfusion. A machine-like murmur (A) is typically associated with patent ductus arteriosus. Severe cyanosis (B) is more commonly seen in conditions like Tetralogy of Fallot. Pulmonary edema (D) is often seen in congestive heart failure.