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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.
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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.
What is the nurse's best response?
- A. Squatting increases the return of venous blood back to the heart.
- B. Squatting decreases arterial blood flow away from the heart.
- C. Squatting is a common resting position when a child is tachycardic.
- D. Squatting increases the workload of the heart.
Correct Answer: A
Rationale: Squatting in tetralogy of Fallot increases venous return, improving systemic circulation and reducing cyanosis.
What does the nurse recognize that this indicates?
- A. Seizure activity
- B. Hypoxia
- C. Sydenham's chorea
- D. Decreasing level of consciousness
Correct Answer: C
Rationale: Sydenham's chorea, characterized by involuntary limb movements, is a neurological manifestation of rheumatic fever.
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.
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.