Nokea
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.
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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.
Which is the most appropriate nursing action related to the administration of digoxin (Lanoxin) to an infant?
- A. Counting the apical rate for 30 seconds before administering the medication
- B. Withholding a dose if the apical heart rate is less than 100 beats/minute
- C. Repeating a dose if the child vomits within 30 minutes of the previous dose
- D. Checking respiratory rate and blood pressure before each dose
Correct Answer: B
Rationale: Withholding digoxin if the infant's heart rate is below 100 beats/minute prevents potential toxicity and ensures safety.
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.
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.
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.