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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.
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How long should a 4-year-old child recovering from rheumatic fever need to receive monthly injections of penicillin G?
- A. 1 year
- B. 2 years
- C. 5 years
- D. 10 years
Correct Answer: C
Rationale: Monthly penicillin G injections for at least 5 years prevent recurrent rheumatic fever in children.
Through what does the infant born with hypoplastic left heart syndrome acquire oxygenated blood?
- A. The patent ductus arteriosus
- B. A ventricular septal defect
- C. The closure of the foramen ovale
- D. An atrial septal defect
Correct Answer: D
Rationale: An atrial septal defect allows oxygenated blood to shunt from the left to the right side, supporting circulation in hypoplastic left heart syndrome.
What does the nurse understand regarding why dyspnea occurs?
- A. Blood is circulated through the lungs again, causing pulmonary circulatory congestion.
- B. Blood is shunted past the pulmonary circulation, causing pulmonary hypoxia.
- C. Blood is shunted past cardiac arteries, causing myocardial hypoxia.
- D. Blood is circulated through the ductus from the pulmonary artery to the aorta, bypassing the left side of the heart.
Correct Answer: A
Rationale: In patent ductus arteriosus, oxygenated blood recycles through the lungs, causing pulmonary congestion and dyspnea.
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.
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.