- A chest x-ray is ordered for a child with suspected cardiac problems. The child’s parent asks the nurse, “What will the radiograph show about the heart?” What knowledge about the x-ray film should the nurse base her response on?
a. It will show the bones of the chest but not the heart.
b. It will measure electrical potential generated by the heart muscle.
c. It will provide a permanent record of heart size and configuration.
d. It will provide a computerized image of heart vessels and tissues.
ANS: C
A chest x-ray provides information on the heart size and pulmonary blood flow patterns, providing a baseline for future comparisons. The heart, sternum, and ribs will be visible. Electrocardiography measures the electrical potential generated from heart muscle. Echocardiography produces a computerized image of the heart vessels and tissues by using sound waves.
- Which complication may occur after a cardiac catheterization?
a. Transient dysrhythmias
b. Hypostatic pneumonia
c. Heart failure
d. Rapidly increasing blood pressure
ANS: A
Because a catheter is introduced into the heart, there is a risk that catheter-induced transient dysrhythmias could occur during the procedure. Hypostatic pneumonia, heart failure, and rapidly increasing blood pressure are not risks usually associated with cardiac catheterization.
- A 4-year-old child is scheduled for a cardiac catheterization. Which statement reflects the correct way for the nurse to provide preoperative teaching?
a. It should be given to his parents because he is too young to understand.
b. It should be detailed in regard to the actual procedures so he will know what to
expect.
c. It should be done several days before the procedure so that he will be prepared.
d. It should be adapted to his level of development so that he can understand.
ANS: D
Preoperative teaching should always be adapted to the child’s stage of development. The caregivers also benefit from the same explanations. The parents may ask additional questions, which should be answered, but the child needs to receive the information in a way he can understand. This age group does not understand in-depth descriptions. Preschoolers should be prepared close to the time of the cardiac catheterization.
- The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is “too wet.” The nurse finds the bandage and bed soaked with blood. What is the priority nursing action?
a. Notify the physician.
b. Apply a new bandage with more pressure.
c. Place the girl in the Trendelenburg position.
d. Apply direct pressure above the catheterization site.
ANS: D
If bleeding occurs, the nurse should apply direct, continuous pressure 2.5 cm above the percutaneous skin site to localize pressure over the vessel puncture. Notifying the physician and applying a new bandage with more pressure can be done after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. The Trendelenburg position would not be helpful, as it would increase the drainage from the lower extremities.
- Which defect results in increased pulmonary blood flow?
a. Pulmonic stenosis
b. Tricuspid atresia
c. Atrial septal defect
d. Transposition of the great arteries
ANS: C
The atrial septal defect results in increased pulmonary blood flow. Blood flows from the left atrium (higher pressure) into the right atrium (lower pressure) and then to the lungs via the pulmonary artery. Pulmonic stenosis is an obstruction to blood flowing from the ventricles. Tricuspid atresia results in decreased pulmonary blood flow. Transposition of the great arteries results in mixed blood flow.
- Which structural defects constitute tetralogy of Fallot?
a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular
hypertrophy
b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular
hypertrophy
c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular
hypertrophy
ANS: A
Tetralogy of Fallot has these four characteristics: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. There is pulmonary stenosis but not atrial stenosis, and right ventricular hypertrophy, not left ventricular hypertrophy in tetralogy of Fallot, and an atrial septal defect, not aortic hypertrophy, is present.
- Which is best described as the heart’s inability to pump an adequate amount of blood to the systemic circulation at normal filling pressures?
a. Pulmonary congestion
b. Congenital heart defect
c. Heart failure
d. Systemic venous congestion
ANS: C
The definition of heart failure is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the metabolic demands of the body. Pulmonary congestion is an excessive accumulation of fluid in the lungs. A congenital heart defect is a malformation of the heart present at birth. Systemic venous congestion is an excessive accumulation of fluid in the systemic vasculature.
- What is a clinical manifestation of the systemic venous congestion that can occur with heart failure?
a. Tachypnea
b. Tachycardia
c. Peripheral edema
d. Pale, cool extremities
ANS: C
Peripheral edema, especially periorbital edema, is a clinical manifestation of systemic venous congestion. Tachypnea is a manifestation of pulmonary congestion. Tachycardia and pale, cool extremities are clinical manifestations of impaired myocardial function.
- What is a beneficial effect of administering digoxin (Lanoxin)?
a. It decreases edema.
b. It decreases cardiac output.
c. It increases heart size.
d. It increases venous pressure.
ANS: A
Digoxin has a rapid onset and is useful in increasing cardiac output, decreasing venous pressure, and, as a result, decreasing edema. Cardiac output is increased by digoxin, while heart size and venous pressure are decreased.
- Which drug is an angiotensin-converting enzyme (ACE) inhibitor?
a. Captopril (Capoten)
b. Furosemide (Lasix)
c. Spironolactone (Aldactone)
d. Chlorothiazide (Diuril)
ANS: A
Captopril is an ACE inhibitor. Furosemide is a loop diuretic. Spironolactone blocks the action of aldosterone. Chlorothiazide works on the distal tubules.
- Which is a common sign of digoxin toxicity? a. Seizures
b. Vomiting
c. Bradypnea
d. Tachycardia
ANS: B
Vomiting is a common sign of digoxin toxicity. Seizures are not associated with digoxin toxicity. The child will have a slower heart rate, not respiratory rate.
- The parents of a young child with heart failure tell the nurse that they are “nervous” about giving digoxin. What knowledge should the nurse include in her response?
a. It is a safe, frequently used drug.
b. It is difficult to either overmedicate or undermedicate with digoxin.
c. Parents lack the expertise necessary to administer digoxin.
d. Parents must learn specific, important guidelines for administration of digoxin.
ANS: D
Digoxin is frequently used, but has a narrow therapeutic range. The difference between therapeutic, toxic, and lethal doses is very minor. Very small amounts of the liquid are given to infants, which makes it easy to under- or overmedicate. Parents may lack the necessary expertise to administer the drug at first, but with discharge instructions they should be prepared to administer the drug safely and monitor for adverse effects.
- As part of the treatment for heart failure, the child takes the diuretic furosemide. When teaching home care, the nurse encourages the family to give the child foods such as bananas, oranges, and leafy vegetables. What are these foods high in?
a. Chlorides
b. Potassium
c. Sodium d. Vitamins
ANS: B
Diuretics that work on the proximal and distal renal tubules contribute to increased losses of potassium, so the child’s diet should be supplemented with potassium.
- An 8-month-old infant has a hypercyanotic spell while blood is being drawn. What is the nurse’s initial action?
a. Assess for neurological defects.
b. Place the child in the knee–chest position.
c. Begin cardiopulmonary resuscitation.
d. Prepare the family for imminent death.
ANS: B
The first action is to place the infant in the knee-chest position. Blow-by oxygen may be indicated. Neurological defects are unlikely. The child should be assessed for airway, breathing, and circulation. Often calming the child and administering oxygen and morphine can alleviate the hypercyanotic spell.
- The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes that a risk of cerebrovascular accidents (strokes) exists. What is an important objective to decrease this risk?
a. Minimize seizures.
b. Prevent dehydration.
c. Promote cardiac output.
d. Reduce energy expenditure.
ANS: B
In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in hypoxemic children because it increases the risk of strokes. Minimizing seizures, promoting cardiac output, and reducing energy expenditure will not reduce the risk of cerebrovascular accidents.
- Parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. What knowledge should inform the nurse’s reply?
a. The child needs opportunities to play with peers.
b. The child needs to understand that peers’ activities are too strenuous.
c. Parents can meet all the child’s needs.
d. Constant parental supervision is needed to avoid overexertion.
ANS: A
The child needs opportunities for social development. Children usually limit their activities if allowed to set their own pace. Parents must be encouraged to seek appropriate social activities for the child, especially before kindergarten. The child needs to engage in activities that foster independence.
- When preparing a school-age child and the family for heart surgery, what should the nurse consider?
a. Don’t show the child unfamiliar equipment.
b. Let the child hear the sounds of an electrocardiograph monitor.
c. Avoid mentioning postoperative discomfort and interventions.
d. Explain that an endotracheal tube will not be needed if the surgery goes well.
ANS: B
The child and family should be exposed to the sights and sounds of the critical care unit. The nurse should emphasize all positive, non-frightening aspects of the environment. The child should be shown unfamiliar equipment, and its use should be demonstrated on a doll. The nurse should carefully prepare the child for the postoperative experience, including intravenous (IV) lines, the incision, and the endotracheal tube.
- Seventy-two hours after cardiac surgery, a young child has a temperature of 37.7°C. What should the nurse do?
a. Keep the child warm with blankets.
b. Apply a hypothermia blanket.
c. Record the temperature on the nurses’ notes.
d. Report these findings to the physician.
ANS: D
In the first 24 to 48 hours after surgery, the body temperature may increase to 37.7°C (100°F) as part of the inflammatory response to tissue trauma. If the temperature is higher or continues after this period, it is most likely a sign of infection, and immediate investigation is indicated. Blankets should be removed from the child to keep the temperature from increasing. A hypothermia blanket is not indicated for this level of temperature. The temperature should be recorded, but the physician must be notified for evaluation.
- What should the nurse do 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.
ANS: C
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 can be avoided by using the appropriate technique.
- The nurse is caring for a child after heart surgery. What should be done if there is evidence of cardiac tamponade?
a. Increase analgesia.
b. Apply warming blankets.
c. Immediately report this to the physician.
d. Encourage the child to cough, turn, and breathe deeply.
ANS: C
If evidence is noted of cardiac tamponade, caused by blood or fluid in the pericardial space constricting the heart, the physician must be notified immediately of this life-threatening complication. Increasing analgesia may be done before the physician drains the fluid, but the physician must be notified first. Warming blankets are not indicated at this time. Encouraging the child to cough, turn, and breathe deeply should be deferred until after the physician’s evaluation.
- What is one important thing the nurse should do when removing chest tubes from a child?
a. Explain that it is not painful.
b. Explain that only a Band-Aid will be needed.
c. Administer analgesics before the procedure.
d. Expect bright red drainage for several hours after removal.
ANS: C
It is appropriate to prepare the child for the removal of chest tubes with analgesics. Short-acting medications can be used that are administered through an existing intravenous line. The chest tube removal will cause a sharp, momentary pain, and this should not be misrepresented to the child. A petroleum gauze/air-tight dressing is needed, but it is not a pain-free procedure. Little or no drainage should be found on removal.
- What is the most common causative agent of bacterial endocarditis?
a. Staphylococcus albus
b. Streptococcus hemolyticus
c. Staphylococcus albicans
d. Streptococcus viridans
ANS: D
Streptococcus viridans is the most common causative agent in bacterial (infective) endocarditis. Staphylococcus albus, Streptococcus hemolyticus, and Staphylococcus albicans are not common causative agents.
- What is the name of the painful, pea-sized nodules that may appear on the pads of the fingers or toes in bacterial endocarditis?
a. Osler nodes
b. Janeway lesions
c. Subcutaneous nodules
d. Aschoff nodes
ANS: A
Osler nodes are red, painful, intradermal nodes found on pads of the phalanges in bacterial endocarditis. Janeway lesions are painless hemorrhagic areas found on the palms and soles in bacterial endocarditis. Subcutaneous nodules are non-tender swellings located over bony prominences, commonly found in rheumatic fever. Aschoff nodules are small nodules composed of cells and leukocytes found in the interstitial tissues of the heart in rheumatic myocarditis.
- What is the primary nursing intervention for preventing bacterial endocarditis?
a. Institute measures to prevent dental procedures.
b. Counsel parents of high-risk children about prophylactic antibiotics.
c. Observe children for complications such as embolism and heart failure.
d. Encourage restricted mobility in susceptible children
ANS: B
The nurse must counsel the parents of high-risk children about both the need for prophylactic antibiotics for dental procedures and the necessity of maintaining excellent oral health. The child’s dentist should be aware of the child’s cardiac condition. Dental procedures should continue to be done to maintain a high level of oral health. Observing for complications and encouraging restricted mobility in susceptible children should be done, but maintaining good oral health and prophylactic antibiotics is the most important.
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Chapter 32: developmental influences30
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chapter 33: Communication, History, Physical, and Developmental Assessment34
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Chapter 35: infant and family32
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chapter 36: Toddler and family26
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chapter 37: pre-schooler26
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Chapter 39:The Adolescent and Family25
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Chapter 40: Chronic Illness, Complex Conditions, and End-of-Life Care25
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chapter 45: Respiratory dysfunction35
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Chapter 46: Gastrointestinal Dysfunction36
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Chapter 47: Cardiovascular dysfunction36
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Chapter 48: Hematological or Immunological Dysfunction35
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Chapter 49: Genitourinary Dysfunction27
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Chapter 50: Cerebral dysfunction38
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Chapter 51: Endocrine dysfunction26
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Chapter 52: Integumentary dysfuction43
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Chapter 53: Musculoskeletal or Articular Dysfunction24
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Chapter 54: Neuromuscular or Muscular Dysfunction14
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Chapter 41: Cognitive and Sensory Impairment27
