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On what understanding does the nurse base a response?
- A. Clubbing occurs as a result of untreated congestive heart failure.
- B. Clubbing occurs as a result of a left-to-right shunting of blood.
- C. Clubbing occurs as a result of decreased cardiac output.
- D. Clubbing occurs as a result of chronic hypoxia.
Correct Answer: D
Rationale: Chronic hypoxia in tetralogy of Fallot leads to clubbing of the fingertips due to prolonged low oxygen levels.
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Which congenital cardiac defect(s) cause(s) increased pulmonary blood flow?
- A. Atrial septal defects (ASDs)
- B. Tetralogy of Fallot
- C. Dextroposition of aorta
- D. Patent ductus arteriosus
- E. Ventricular septal defects (VSDs)
Correct Answer: A,D,E
Rationale: ASDs, patent ductus arteriosus, and VSDs cause increased pulmonary blood flow due to left-to-right shunting.
What are the four structural heart anomalies that make up the tetralogy of Fallot?
- A. Hypertrophied right ventricle
- B. Patent ductus arteriosus
- C. Ventral septal defect
- D. Narrowing of pulmonary artery
- E. Dextroposition of aorta
Correct Answer: A,B,D,E
Rationale: Tetralogy of Fallot includes a hypertrophied right ventricle, patent ductus arteriosus, pulmonary artery stenosis, and dextroposition of the aorta. Note: The document incorrectly lists 'ventral septal defect' instead of 'ventricular septal defect,' but the correct term is assumed.
What finding would the nurse expect when measuring blood pressure on all four extremities of a child with coarctation of the aorta?
- A. Blood pressure higher on the right side
- B. Blood pressure higher on the left side
- C. Blood pressure lower in the arms than in the legs
- D. Blood pressure lower in the legs than in the arms
Correct Answer: D
Rationale: Coarctation of the aorta causes higher blood pressure in the arms due to obstruction distal to the defect, resulting in lower pressure in the legs.
The nurse is caring for a child with a diagnosis of Kawasaki disease. The child's parent asks the nurse, 'How does Kawasaki disease affect my child's heart and blood vessels?' On what understanding is the nurse's response based?
- A. Inflammation weakens blood vessels, leading to aneurysm.
- B. Increased lipid levels lead to the development of atherosclerosis.
- C. Untreated disease causes mitral valve stenosis.
- D. Altered blood flow increases cardiac workload with resulting heart failure.
Correct Answer: A
Rationale: Kawasaki disease causes vasculitis, weakening vessel walls and increasing the risk of aneurysms.
What assessment(s) in a child with tetralogy of Fallot would indicate the child is experiencing a paroxysmal hypercyanotic episode?
- A. Spontaneous cyanosis
- B. Dyspnea
- C. Weakness
- D. Dry cough
- E. Syncope
Correct Answer: A,B,C,E
Rationale: Spontaneous cyanosis, dyspnea, weakness, and syncope are indicators of a 'tet' spell in tetralogy of Fallot.