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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.
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What does the nurse recognize as a sign of digoxin toxicity?
- A. Restlessness
- B. Decreased respiratory rate
- C. Increased urinary output
- D. Vomiting
Correct Answer: D
Rationale: Vomiting is a common sign of digoxin toxicity, along with nausea, anorexia, and pulse irregularities.
Which statement by the father leads the nurse to determine he understood the instructions?
- A. If the baby turns blue, I will hold him against my shoulder with his knees bent up toward his chest.'
- B. If the baby turns blue, I will lay him down on a firm surface with his head lower than the rest of his body.'
- C. If the baby turns blue, I will immediately put the baby upright in an infant seat.'
- D. If the baby turns blue, I will put the baby in supine position with his head elevated.'
Correct Answer: A
Rationale: The knee-chest position during a hypercyanotic spell in tetralogy of Fallot increases venous return and reduces cyanosis.
How would the nurse caring for an infant with congestive heart failure (CHF) modify feeding techniques to adapt for the child's weakness and fatigue?
- A. Feeding more frequently with smaller feedings
- B. Using a soft nipple with enlarged holes
- C. Holding and cuddling the child during feeding
- D. Substituting glucose water for formula
- E. Offering high-caloric formula
Correct Answer: A,B,C,E
Rationale: Smaller, frequent feedings, soft large-holed nipples, cuddling, and high-calorie formula reduce fatigue and support nutrition in CHF.
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.