chapter 025

2Test BankMosby items and derived items 2008, 2005, 2001 by Mosby Inc.Mosby items and derived items 2008, 2005, 2001 by Mosby Inc.Hockenberry, et al.: Wong's Essential of Pediatric Nursing, 8th Edition

Chapter 25: The Child with Cardiovascular Dysfunction

MULTIPLE CHOICE

1.A chest radiograph film is ordered for a child with suspected cardiac problems. The childs parent asks the nurse, What will the radiograph show about the heart? The nurses response should be based on knowledge that the x-ray film will do which of the following?1.Show bones of chest but not the heart2.Measure electrical potential generated from heart muscle3.Provide permanent record of heart size and configuration4.Provide computerized image of heart vessels and tissues

ANS:33.A chest radiograph will provide information on the heart size and pulmonary blood-flow patterns. It will be provide a baseline for future comparisons.1.The heart will be visible, as well as the sternum and ribs.2.Electrocardiography (ECG) measures the electrical potential generated from heart muscle.4.Echocardiography will produce a computerized image of the heart vessels and tissues by using sound waves.

DIF:Cognitive Level: ComprehensionTOP:Integrated Process: Teaching/LearningMSC:Area of Client Needs: Health Promotion and Maintenance: Prevention and Early Detection of Disease

2.Which of the following is a complication that may occur after a cardiac catheterization?1.Cardiac arrhythmia2.Hypostatic pneumonia3.Congestive heart failure4.Rapidly increasing blood pressure

ANS:11.Because a catheter is introduced into the heart, a risk exists of catheter-induced dysrhythmias occurring during the procedure. These are usually transient.2, 3, and 4. These are not risks usually associated with cardiac catheterization.

DIF:Cognitive Level: ComprehensionTOP:Integrated Process: Nursing Process: Problem IdentificationMSC:Area of Client Needs: Physiological Integrity: Reduction of Risk Potential

20Test Bank3.Jos is a 4-year-old child scheduled for a cardiac catheterization. Preoperative teaching should be:1.Directed at his parents, because he is too young to understand.2.Detailed in regard to the actual procedures so he will know what to expect.3.Done several days before the procedure so that he will be prepared.4.Adapted to his level of development so that he can understand.

ANS:44.Preoperative teaching should always be directed at the childs stage of development. The caregivers also benefit from the same explanations.1 and 2. The parents may ask additional questions, which should be answered, but the child needs to receive the information based on developmental level. This age group will not understand in-depth descriptions.3.Preschoolers should be prepared close to the time of the cardiac catheterization.

DIF:Cognitive Level: ApplicationTOP:Integrated Process: Teaching/LearningMSC:Area of Client Needs: Physiological Integrity: Reduction of Risk Potential

4.Which of the following explanations regarding cardiac catheterization is appropriate for a preschool child?1.Postural drainage will be performed every 4 to 6 hours after the test.2.It is necessary to be completely asleep during the test.3.The test is very short, usually taking less than 1 hour.4.When the procedure is done, you will have to keep your leg straight for at least 4 hours.

ANS:44.The childs leg will have to be maintained in a straight position for approximately 4 hours. Younger children can be held in the parents lap with the leg maintained in the correct position.1.This is not done unless the child has corresponding pulmonary problems.2.The child should be sedated to lie still, but being completely asleep is not necessary.3.The test will vary in length of time from start to finish.


5.Nursing interventions for the child after a cardiac catheterization would include which of the following?1.Allow ambulation as tolerated.2.Monitor vital signs every 2 hours.3.Assess the affected extremity for temperature and color.4.Check pulses above the catheterization site for equality and symmetry.

ANS:33.The extremity that was used for access for the cardiac catheterization must be checked for temperature and color. Coolness and blanching may indicate arterial occlusion.1.The child should remain on bed rest with the leg extended for a minimum of 4 hours.2.Initially vital signs are taken every 15 minutes, with emphasis on a heart rate counted for 1 minute.4.Pulses above the catheterization site should be not affected by the catheterization. Pulses distal to the site should be monitored.

DIF:Cognitive Level: ComprehensionTOP:Integrated Process: Nursing Process: ImplementationMSC:Area of Client Needs: Physiological Integrity: Reduction of Risk Potential

6.After the child returns from cardiac catheterization, the nurse monitors the childs vital signs. The heart rate should be counted for how many seconds?1.102.153.304.60

ANS:44.After cardiac catheterization, the heart rate should be counted for a full minute to detect evidence of dysrhythmias or bradycardia.1, 2, and 3. These are not sufficient length of times to detect a dysrhythmia after a cardiac catheterization.

DIF:Cognitive Level: ComprehensionTOP:Integrated Process: Nursing Process: AssessmentMSC:Area of Client Needs: Physiological Integrity: Reduction of Risk Potential

7.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. The most appropriate initial nursing action is which of the following?1.Notify physician.2.Apply new bandage with more pressure.3.Place in Trendelenburg position.4.Apply direct pressure above catheterization site.

ANS:44.If bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site to localize pressure over the vessel puncture.1 and 2. These can be done after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained.3.This would not be a helpful intervention. It would increase the drainage from the lower extremities.

DIF:Cognitive Level: AnalysisTOP:Integrated Process: Nursing Process: ImplementationMSC:Area of Client Needs: Physiological Integrity: Reduction of Risk Potential

8.Which of the following should be included in the instructions to an active adolescent who is going home after a cardiac catheterization?1.Avoid tub baths but may shower.2.Maintain strict bed rest for 3 days.3.Leave pressure dressing on for 7 days.4.Stay home from school until Band-Aid is removed.

ANS:11.The catheterization site should be kept relatively dry with a adhesive bandage. Showers are recommended.2 and 4. Strenuous activity must be avoided for several days, but the child can return to school.3.The pressure dressing is removed the day after the catheterization and replaced by an adhesive bandage to keep the area clean.


9.Surgical closure of the ductus arteriosus would do which of the following?1.Stop the loss of unoxygenated blood to the systemic circulation2.Decrease the edema in legs and feet3.Increase the oxygenation of blood4.Prevent the return of oxygenated blood to the lungs

ANS:44.The ductus arteriosus allows blood to flow from the higher-pressure aorta to the lower-pressure pulmonary artery, causing a right-to-left shunt. If this is surgically closed, no additional oxygenated blood (from the aorta) will return to the lungs through the pulmonary artery.1.The aorta carries oxygenated blood to the systemic circulation. Because of the higher pressure in the aorta, blood is shunted into the pulmonary artery and the pulmonary circulation.2.Edema in the legs and feet is usually a sign of congestive heart failure. This repair would not directly affect the edema.3.This would not interfere with the return of oxygenated blood to the lungs.

DIF:Cognitive Level: AnalysisTOP:Integrated Process: Nursing Process: PlanningMSC:Area of Client Needs: Physiological Integrity: Physiological Adaptation

10.Which of the following defects results in increased pulmonary blood flow?1.Pulmonic stenosis2.Tricuspid atresia3.Atrial septal defect4.Transposition of the great arteries

ANS:33.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.1.Pulmonic stenosis is an obstruction to blood flowing from the ventricles.2.Tricuspid atresia results in decreased pulmonary blood flow.4.Transposition of the great arteries results in mixed blood flow.

DIF:Cognitive Level: ComprehensionTOP:Integrated Process: Nursing Process: AssessmentMSC:Area of Client Needs: Physiological Integrity: Physiological Adaptation

11.Which of the following structural defects constitute tetralogy of Fallot?1.Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy2.Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy3.Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy4.Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy

ANS:11.Tetralogy of Fallot has these four characteristics: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy.2.There is pulmonary stenosis but not atrial stenosis in tetralogy of Fallot.3.Right ventricular hypertrophy, not left ventricular hypertrophy is present in tetralogy of Fallot.4.Right ventricular hypertrophy, not left ventricular hypertrophy is present in tetralogy of Fallot, and an atrial septal defect, not aortic hypertrophy, is present.


12.Which of the following defects results in decreased pulmonary blood flow?1.Atrial septal defect2.Tetralogy of Fallot3.Ventricular septal defect4.Patent ductus arteriosus

ANS:22.Tetralogy of Fallot results in decreased blood flow to the lungs. The pulmonic stenosis increases the pressure in the right ventricle, causing the blood to go from right to left across the ventricular septal defect.1, 3, and 4. Atrial and ventricular septal defects and patent ductus arteriosus result in increased pulmonary blood flow.


13.Which of the following is best described as the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures?1.Pulmonary congestion2.Congenital heart defect3.Congestive heart failure4.Systemic venous congestion

ANS:33.The definition of congestive 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.1.Pulmonary congestion is an excessive accumulation of fluid in the lungs.2.Congenital heart defect is a malformation of the heart present at birth.4.Systemic venous congestion is an excessive accumulation of fluid in the systemic vasculature.


14.Which of the following is a clinical manifestation of the systemic venous congestion that can occur with congestive heart failure?1.Tachypnea2.Tachycardia3.Peripheral edema4.Pale, cool extremities

ANS:33.Peripheral edema, especially periorbital edema, is a clinical manifestation of systemic venous congestion.1.Tachypnea is a manifestation of pulmonary congestion.2 and 4. Tachycardia and pale, cool extremities are clinical manifestations of impaired myocardial function.

DIF:Cognitive Level: AnalysisTOP:Integrated Process: Nursing Process: AssessmentMSC:Area of Client Needs: Physiological Integrity: Physiological Adaptation

15.A beneficial effect of administering digoxin (Lanoxin) is that it:1.Decreases edema.2.Decreases cardiac output.3.Increases heart size.4.Increases venous pressure.

ANS:11.Digoxin has a rapid onset and is useful increasing cardiac output, decreasing venous pressure, and as a result, decreasing edema.2.Cardiac output is increased by digoxin.3.Heart size is decreased by digoxin.4.Digoxin decreases venous pressure.

DIF:Cognitive Level: ComprehensionTOP:Integrated Process: Nursing Process: ImplementationMSC:Area of Client Needs: Physiological Integrity: Pharmacologic and Parenteral Therapy

16.Which of the following drugs is an angiotensin-converting enzyme (ACE) inhibitor?1.Captopril (Capoten)2.Furosemide (Lasix)3.Spironolactone (Aldactone)4.Chlorothiazide (Diuril)

ANS:11.Capoten is a drug which is an ACE inhibitor.2.Lasix is a loop diuretic.3.Aldactone blocks the action of aldosterone.4.Diuril works on the distal tubules.


17.An 8-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than which of the following?1.602.703.904.100

ANS:22.If a 1-minute apical pulse is less than 70 for an older child, the digoxin is withheld.1.This is the cut-off for holding the digoxin dose in an adult.3 and 4. Below 90 to 100 is the determination for not giving a digoxin dose to infants and young children.

DIF:Cognitive Level: ComprehensionTOP:Integrated Process: Nursing Process: AssessmentMSC:Area of Client Needs: Physiological Integrity: Pharmacologic and Parenteral Therapy

18.A 6-month-old infant is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than which of the following?1.602.703.90 to 1104.110 to 120

ANS:33.If the 1-minute apical is below 90 to 110, the digoxin should not be given to a 6-month-old.1.This is the cut-off for holding the digoxin dose in an adult.2.This is the determining heart rate to hold a dose of digoxin for an older child.4.This is an acceptable heart rate to administer digoxin to a 6-month-old.


19.Which of the following is a common sign of digoxin toxicity?1.Seizures2.Vomiting3.Bradypnea4.Tachycardia

ANS:22.Vomiting is a common sign of digoxin toxicity.1.Seizures are not associated with digoxin toxicity.3.The child will have a slower heart rate, not respiratory rate.4.The heart rate will be slower, not faster.


20.The parents of a young child with congestive heart failure tell the nurse that they are nervous about giving digoxin. The nurses response should be based on which of the following?1.It is a very safe, frequently used drug.2.It is difficult to either overmedicate or undermedicate with digoxin.3.Parents lack the expertise necessary to administer digoxin.4.Parents must learn specific, important guidelines for administration of digoxin.

ANS:44.Digoxin has a narrow therapeutic range. The margin of safety between therapeutic, toxic, and lethal doses is very small. Specific guidelines are available for parents to learn how to administer the drug safely and to monitor for side effects.1 and 2. Digoxin is a frequently used drug, but it has a narrow therapeutic range. Very small amounts of the liquid are given to infants making it easy to over- or undermedicate.3.Parents may lack the necessary expertise to administer the drug at first, but with discharge preparation, they should be prepared to administer the drug safely.

DIF:Cognitive Level: AnalysisTOP:Integrated Process: Teaching/LearningMSC:Area of Client Needs: Physiological Integrity: Pharmacologic and Parenteral Therapy

21.The infant with congestive heart failure has a need for:1.Increased calories.2.Increased fluids.3.Decreased protein.4.Decreased fat.

ANS:11.The metabolic rate of infants with congestive heart failure is greater because of poor cardiac function and increased heart and respiratory rates. Their caloric needs are greater than those of the average infants, yet their ability to take in the calories is diminished by their fatigue.2.Fluids must be carefully monitored because of the congestive heart failure.3 and 4. The diet should include increased protein and increased fat to facilitate the childs intake of sufficient calories.


22.As part of the treatment for congestive heart failure, the child takes the diuretic furosemide. As part of teaching home care, the nurse encourages the family to give the child foods such as bananas, oranges, and leafy vegetables. These foods are recommended for this child because they are high in which of the following?1.Chlorides2.Potassium3.Sodium4.Vitamins

ANS:22.Diuretics that work on the proximal and distal renal tubules contribute to increased losses of potassium. The childs diet should be supplemented with this electrolyte.1, 3, and 4. With this type of diuretic, potassium must be monitored and supplemented as needed.DIF:Cognitive Level: ComprehensionTOP:Integrated Process: Teaching/LearningMSC:Area of Client Needs: Physiological Integrity: Pharmacologic and Parenteral Therapy

23.Which of the following is a sign of hypokalemia?1.Apnea2.Oliguria3.Twitching4.Muscle weakness

ANS:44.Muscle weakness is a characteristic clinical manifestation of hypokalemia.1, 2, and 3. These are not indications of hypokalemia.


24.An 8-month-old infant has a hypercyanotic spell while blood is being drawn. The nurses first action should be which of the following?1.Assess for neurologic defects.2.Place the child in the knee-chest position3.Begin cardiopulmonary resuscitation.4.Prepare family for imminent death.

ANS:22.The first action is to place the infant in the knee-chest position. Blow-by oxygen may be indicated.1.Neurologic defects are unlikely.3 and 4. The child should be assessed for airway, breathing, and circulation. Often, calming the child and administering oxygen and morphine can alleviate the hypercyanotic spell.

DIF:Cognitive Level: ApplicationTOP:Integrated Process: Nursing Process: ImplementationMSC:Area of Client Needs: Physiological Integrity: Physiological Adaptation

25.The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes that a risk exists of cerebrovascular accidents (strokes). Which of the following is an important objective to decrease this risk?1.Minimize seizures2.Prevent dehydration3.Promote cardiac output4.Reduce energy expenditure

ANS:22.In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in hypoxemic children because it potentiates the risk of strokes.1, 3, and 4. Minimizing seizures, promoting cardiac output, and reducing energy expenditure will not reduce the risk of cerebrovascular accidents.

DIF:Cognitive Level: AnalysisTOP:Integrated Process: Nursing Process: ImplementationMSC:Area of Client Needs: Physiological Integrity: Physiological Adaptation

26.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. The nurses reply should be based on which of the following?1.Child needs opportunities to play with peers.2.Child needs to understand that peers activities are too strenuous.3.Parents can meet all the childs needs.4.Constant parental supervision is needed to avoid overexertion.

ANS:11.The child needs opportunities for social development. Children usually limit their activities if allowed to set their own pace.2.The child will limit activities as necessary.3.Parents must be encouraged to seek appropriate social activities for the child, especially before kindergarten. The child needs to have activities that foster independence.4.The child will be able to regulate activities.

DIF:Cognitive Level: AnalysisTOP:Integrated Process: Teaching/LearningMSC:Area of Client Needs: Psychosocial Integrity: Coping and Adaptation

27.Which of the following should the nurse consider when preparing a school-age child and the family for heart surgery?1.Unfamiliar equipment should not be shown.2.Let child hear the sounds of an ECG monitor.3.Avoid mentioning postoperative discomfort and interventions.4.Explain that an endotracheal tube will not be needed if the surgery goes well.

ANS:22.The child and family should be exposed to the sights and sounds of the intensive care unit (ICU). All positive, nonfrightening aspects of the environment are emphasized.1.The child should be shown unfamiliar equipment and its use demonstrated on a doll.3 and 4. Carefully prepare the child for the postoperative experience, including intravenous (IV) lines, incision, and endotracheal tube.

DIF:Cognitive Level: AnalysisTOP:Integrated Process: Teaching/LearningMSC:Area of Client Needs: Psychosocial Integrity: Coping and Adaptation

28.Seventy-two hours after cardiac surgery, a young child has a temperature of 101 F. The nurse should do which of the following?1.Keep child warm with blankets.2.Apply a hypothermia blanket.3.Record temperature on nurses notes.4.Report findings to physician.

ANS:44.In the first 24 to 48 hours after surgery, the body temperature may increase to 37.7 C or 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 an infection and immediate investigation is indicated.1.Blankets should be removed from the child to keep the temperature from increasing.2.Hypothermia blanket is not indicated for this level of temperature.3.The temperature should be recorded, but the physician must be notified for evaluation.


29.Which of the following is an important nursing consideration when suctioning a young child who has had heart surgery?1.Perform suctioning at least every hour.2.Suction for no longer than 30 seconds at a time.3.Administer supplemental oxygen before and after suctioning.4.Expect symptoms of respiratory distress when suctioning.

ANS:33.If suctioning is indicated, supplemental oxygen is administered with a manual resuscitation bag before and after the procedure to prevent hypoxia.1.Suctioning should be done only as indicated, not on a routine basis.2.The child should be suctioned for no more than 5 seconds at one time.4.Symptoms of respiratory distress are to be avoided by using appropriate technique.


30.The nurse is caring for a child after heart surgery. Which of the following should the nurse do if evidence is found of cardiac tamponade?1.Increase analgesia.2.Apply warming blankets.3.Immediately report this to physician.4.Encourage child to cough, turn, and breathe deeply.

ANS:33.If evidence is noted of cardiac tamponade, blood or fluid in the pericardial space constricting the heart, the physician is notified immediately of this life-threatening complication.1.This may be done before the physician drains the fluid, but the physician must be notified.2.Warming blankets are not indicated at this time.4.This should be deferred till after the evaluation by the physician.

DIF:Cognitive Level: AnalysisTOP:Integrated Process: Nursing Process: ImplementationMSC:Area of Client Needs: Physiological Integrity: Physiological Adaptation

31.Which of the following is an important nursing consideration when chest tubes will be removed from a child?1.Explain that it is not painful.2.Explain that only a Band-Aid will be needed3.Administer analgesics before procedure.4.Expect bright red drainage for several hours after removal.

ANS:33.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 IV line.1.A sharp, momentary pain is felt. This should not be misrepresented to the child.2.A petroleum gauze/air-tight dressing will be needed, but it is not a pain-free procedure.4.Little or no drainage should be found on removal.


32.What is the most common causative agent of bacterial endocarditis?1.Staphylococcus albus2.Streptococcus hemolyticus3.Staphylococcus albicans4.Streptococcus viridans

ANS:44.Staphylococcus viridans is the most common causative agent in bacterial (infective) endocarditis.1, 2, and 3. These are not common causative agents.


33.What painful, tender, pea-sized nodules may appear on the pads of the fingers or toes in bacterial endocarditis?1.Osler nodes2.Janeway lesions3.Subcutaneous nodules4.Aschoff nodes

ANS:11.Osler nodes are red, painful, intradermal nodes found on pads of the phalanges in bacterial endocarditis.2.Janeway lesions are painless hemorrhagic areas on palms and soles in bacterial endocarditis.3.Subcutaneous nodules are nontender swellings, located over bony prominences, commonly found in rheumatic fever.4.Aschoff nodules are small nodules composed of cells and leukocytes found in the interstitial tissues of the heart in rheumatic myocarditis.


34.The primary nursing intervention to prevent bacterial endocarditis is which of the following?1.Institute measures to prevent dental procedures.2.Counsel parents of high-risk children about prophylactic antibiotics.3.Observe children for complications, such as embolism and heart failure.4.Encourage restricted mobility in susceptible children.

ANS:22.The objective of nursing care is to 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 childs dentist should be aware of the childs cardiac condition.1.Dental procedures should be done to maintain a high level of oral health. Prophylactic antibiotics are necessary.3 and 4. These should be done, but maintaining good oral health and prophylactic antibiotics is important.

DIF:Cognitive Level: ApplicationTOP:Integrated Process: Nursing Process: AssessmentMSC:Area of Client Needs: Physiological Integrity: Reduction of Risk Potential

35.Which of the following is a common, serious complication of rheumatic fever?1.Seizures2.Cardiac arrhythmias3.Pulmonary hypertension4.Cardiac valve damage

ANS:44.Cardiac valve damage is the most significant complication of rheumatic fever.1, 2, and 3. These are not common complications of rheumatic fever.


36.Which of the following is a major clinical manifestation of rheumatic fever?1.Polyarthritis2.Osler nodes3.Janeway spots4.Splinter hemorrhages of distal third of nails

ANS:11.Polyarthritis, which is swollen, hot, red, and painful joints. The affected joints will change every 1 to 2 days. Primarily the large joints are affected.2, 3, and 4. Osler nodes, Janeway spots, and splinter hemorrhages are characteristic of infective endocarditis.


37.Therapeutic management of the child with rheumatic fever includes:1.Administration of penicillin.2.Avoid salicylates (aspirin).3.Strict bed rest for 4 to 6 weeks.4.Administration of corticosteroids if chorea develops.

ANS:11.The goal of medical management is the eradication of the hemolytic streptococci. Penicillin is the drug of choice.2.Salicylates can be used to control the inflammatory process, especially in the joints, and reduce the fever and discomfort.3.Bed rest is recommended for the acute febrile stage, but it does not need to be strict.4.The chorea is transient and will resolve without treatment.

DIF:Cognitive Level: AnalysisTOP:Integrated Process: Nursing Process: ImplementationMSC:Area of Client Needs: Physiological Integrity: Pharmacologic and Parenteral Therapy

38.Which of the following actions by the school nurse is important in the prevention of rheumatic fever?1.Encourage routine cholesterol screenings.2.Conduct routine blood pressure screenings.3.Refer children with sore throats for throat cultures.4.Recommend salicylates instead of acetaminophen for minor discomforts.

ANS:33.Nurses have a role in prevention; primarily in screening school-age children for sore throats caused by group A streptococci. This can be by actively participating in throat culture screening or by referring children with possible streptococcal sore throats for testing.1 and 2. These do not facilitate the recognition and treatment of group A hemolytic streptococci.4.Salicylates should be avoided routinely because of the risk of Reye syndrome after viral illnesses.

DIF:Cognitive Level: AnalysisTOP:Integrated Process: Nursing Process: PlanningMSC:Area of Client Needs: Health Promotion and Maintenance: Prevention and Early Detection of Disease

39.When discussing hyperlipidemia with a group of adolescents, the nurse should explain that high levels of what are thought to protect against cardiovascular disease?1.Cholesterol2.Triglycerides3.Low-density lipoproteins (LDLs)4.High-density lipoproteins (HDLs)

ANS:44.HDLs contain very low concentrations of triglycerides, relatively little cholesterol, and high levels of proteins. It is thought that HDLs protect against cardiovascular disease.1, 2, and 3. Cholesterol, triglycerides, and LDLs are not protective against cardiovascular disease.

DIF:Cognitive Level: ApplicationTOP:Integrated Process: Teaching/LearningMSC:Area of Client Needs: Health Promotion and Maintenance: Prevention and Early Detection of Disease

40.Which of the following is the leading cause of death after heart transplantation?1.Infection2.Rejection3.Cardiomyopathy4.Congestive heart failure

ANS:22.The posttransplant course is complex. The leading cause of death after cardiac transplant is rejection.1.Infection is a continued risk secondary to the immunosuppression necessary to prevent rejection.3.Cardiomyopathy is one of the indications for cardiac transplant.4.This is not a leading cause of death.


41.When caring for the child with Kawasaki disease, the nurse should know which of the following?1.Childs fever is usually responsive to antibiotics within 48 hours.2.Principal area of involvement is the joints.3.Aspirin is contraindicated.4.Therapeutic management includes administration of gamma globulin and aspirin.

ANS:44.High-dose IV gamma globulin and aspirin therapy is indicated to reduce the incidence of coronary artery abnormalities when given within the first 10 days of the illness.1.The fever of Kawasaki disease is unresponsive to antibiotics and antipyretics.2.Mucous membranes, conjunctiva, changes in the extremities, and cardiac involvement are seen.3.Aspirin is part of the therapy.


42.One of the most frequent causes of hypovolemic shock in children is which of the following?1.Sepsis2.Blood loss3.Anaphylaxis4.Congenital heart disease

ANS:22.Blood loss is the most frequent cause of hypovolemic shock in children.1.Sepsis causes septic shock, which is overwhelming sepsis and circulating bacterial toxins.3.Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance.4.Congenital heart disease contributes to hypervolemia, not hypovolemia.


43.Which of the following types of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy?1.Neurogenic shock2.Cardiogenic shock3.Hypovolemic shock4.Anaphylactic shock

ANS:44.Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance.1.Neurogenic shock results from loss of neuronal control, such as the interruption of neuronal transmission that occurs from a spinal cord injury.2.Cardiogenic shock is decreased cardiac output.3.Hypovolemic shock is a reduction in the size of the vascular compartment, decreasing blood pressure, and low central venous pressure.DIF:Cognitive Level: ComprehensionTOP:Integrated Process: Nursing Process: AssessmentMSC:Area of Client Needs: Physiological Integrity: Physiological Adaptation

44.Which of the following clinical manifestations would the nurse expect to see as shock progresses in a child and becomes uncompensated shock?1.Thirst2.Irritability3.Apprehension4.Confusion and somnolence

ANS:44.Confusion and somnolence are beginning signs of uncompensated shock.1, 2, and 3. Thirst, irritability, and apprehension are signs of compensated shock.


45.Which of the following occurs in septic shock?1.Hypothermia2.Increased cardiac output3.Vasoconstriction4.Angioneurotic edema

ANS:22.Increased cardiac output, which results in warm, flushed skin, is one of the manifestations of septic shock.1.Fever and chills are characteristic of septic shock.3.Vasodilation is more common.4.Angioneurotic edema occurs as a manifestation in anaphylactic shock.


46.The nurse suspects shock in a child who is 1-day after surgery. The initial nursing action should be which of the following?1.Obtain blood gases.2.Administer oxygen.3.Place on cardiac monitor.4.Place in Trendelenburg position.

ANS:22.The initial nursing action in shock is to establish ventilatory support. This would be done by the administration of oxygen.1.Oxygen saturation monitoring should be begun. Blood gases would be indicated if alternative methods of monitoring oxygen therapy were not available.3.Monitoring would be indicated to assess the childs status further.4.This would not be indicated.

DIF:Cognitive Level: ComprehensionTOP:Integrated Process: Nursing Process: ImplementationMSC:Area of Client Needs: Physiological Integrity: Physiological Adaptation

47.A child is brought to the emergency department experiencing an anaphylactic reaction to a bee sting. While an airway is being established, the nurse should prepare which of the following medications for immediate administration?1.Diphenhydramine (Benadryl)2.Dopamine3.Epinephrine4.Calcium chloride

ANS:33.After the first priority of establishing an airway, administration of epinephrine is the drug of choice.1.Diphenhydramine, an antihistamine, is usually not used for severe reactions.2 and 4. These are not appropriate drugs for this type of reaction.

DIF:Cognitive Level: ComprehensionTOP:Integrated Process: Nursing Process: AssessmentMSC:Area of Client Needs: Physiological Integrity: Pharmacologic and Parenteral Therapy

48.Clinical manifestations of toxic shock syndrome include which of the following?1.Severe hypertension2.Subnormal temperature3.Erythematous macular rash4.Papular rash over extremities

ANS:33.One of the diagnostic criteria for toxic shock syndrome is a diffuse macular erythroderma.1.Hypotension is one of the manifestations.2.Fever of 38.9 C or higher is a characteristic.4.Desquamation of the palms and soles of the feet occurs about 1 to 2 weeks.


chapter 025

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