Nokea
The nurse is monitoring an infant with a congenital heart disease closely for signs of heart failure. Which early sign should the nurse be most concerned about?
- A. Pallor
- B. Cough
- C. Tachycardia
- D. Slow and shallow breathing
Correct Answer: C
Rationale: Tachycardia is an early sign of heart failure in infants because the heart attempts to compensate for decreased cardiac output by increasing the heart rate.
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Blau syndrome is associated with
- A. Amyloidosis
- B. Sarcoidosis
- C. Hemochromatosis
- D. Myeloma
Correct Answer: B
Rationale: Blau syndrome is associated with sarcoidosis
Which is an important nursing consideration when suctioning a young child who has had heart surgery?
- A. Perform suctioning at least every hour.
- B. Suction for no longer than 30 seconds at a time.
- C. Administer supplemental oxygen before and after suctioning.
- D. Expect symptoms of respiratory distress when suctioning.
Correct Answer: C
Rationale: If suctioning is indicated, supplemental oxygen is administered with a manual resuscitation bag before and after the procedure to prevent hypoxia. Suctioning should be done only as indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at one time. Symptoms of respiratory distress are avoided by using appropriate technique.
Increased left ventricular end diastolic volume is seen in:
- A. Mitral regurgitation
- B. Congestive cardiomyopathy
- C. Hypertrophic obstructive cardiomyopathy
- D. Aortic stenosis
Correct Answer: A
Rationale: Mitral regurgitation leads to increased left ventricular end-diastolic volume due to backflow of blood into the left atrium.
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?
- A. Inappropriate laughter
- B. Increasing anxiety
- C. Weakened cough effort
- D. Asymmetrical weakness
Correct Answer: C
Rationale: A weakened cough effort can lead to respiratory complications, which are life-threatening in ALS patients.
The clinic nurse reviews the record of a child just seen by the health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder?
- A. Pallor
- B. Hyperactivity
- C. Exercise intolerance
- D. Gastrointestinal disturbances
Correct Answer: C
Rationale: Exercise intolerance is a common clinical manifestation of aortic stenosis due to the heart's inability to pump sufficient blood during increased physical activity.