Nokea
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.
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Which comment made by a parent of a 1-month-old infant would alert the nurse about the presence of a congenital heart defect?
- A. He is always hungry.'
- B. He tires out during feedings.'
- C. He is fussy for several hours every day.'
- D. He sleeps all the time.'
Correct Answer: B
Rationale: Fatigue during feedings is a common sign of congenital heart defects due to increased cardiac workload.
What should be the main focus of the nurse when presenting information?
- A. Pharmacological treatment
- B. Surgical interventions available
- C. Patient education
- D. Reduction of aerobic exercise
Correct Answer: C
Rationale: Patient education is the primary focus of a hypertension-prevention program to promote lifestyle changes and awareness.
What diagnostic test does the nurse anticipate?
- A. Barium swallow
- B. Chest x-ray
- C. Electrocardiogram
- D. Echocardiogram
Correct Answer: D
Rationale: An echocardiogram is a noninvasive test to assess heart structure and localize murmurs.
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.
What does the nurse explain that a ventricular septal defect will allow?
- A. Blood to shunt left to right, causing increased pulmonary flow and no cyanosis
- B. Blood to shunt right to left, causing decreased pulmonary flow and cyanosis
- C. No shunting because of high pressure in the left ventricle
- D. Increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating volume
Correct Answer: A
Rationale: A ventricular septal defect allows blood to shunt from the left to the right ventricle due to higher left ventricular pressure, increasing pulmonary flow without causing cyanosis.