UNIT 4

In which part of the cardiovascular system would the nurse expect an increase in pressure in a toddler w/ pulmonic stenosis? a) LA b) RV c) pulmonary vein d) pulmonary artery

b) RV

which assessment finding would indicate improvement in a 4mo old infant admitted to the pediatric unit w/ a diagnosis of CHF? a) decreased tremors b) increased hours of sleep c) weight loss during next 2 days d) more rapid HR w/in 2 days

c) weight loss during next 2 days CHF involves water retention, so weight loss would indicate fluid loss

What are the 3 stages of septic shock?

- hyperdynamic: warm, compensated - normodynamic: cool, decompensated - hypodynamic: COLD, uncompensated

Define sepsis

SIRS in the presence of or as a result of suspected or proven infection

a neonate born at 35 wks gestation has Apgar scores of 8 and 9. At 4hrs of age, the newborn begins to experience respiratory distress, below normal temp in a warm environment, and low blood glucose lvl. Which condition is the nurse concerned about based on these findings? a) hypogylcemia b) bacterial sepsis c) cocaine withdrawal d) meconium aspiration

b) bacterial sepsis

HF dvlps in a 4mo old infant w/ a congenital heart defect, and the infant exhibits marked dyspnea at rest. Which assessment finding would the nurse expect in this infant? a) hypovolemia b) bilateral crackles c) decreased RBC count d) decreased pH and carbon dioxide values

b) bilateral crackles increased blood volume and pressure in lungs from impaired myocardial fctn result in pulmonary edema --> crackles

a toddler is found to have coarctation of aorta. which finding would the nurse expect when taking the child's vital signs? a) irregular heartbeat b) weak femoral pulse c) thready radial pulse d) increased temp

b) weak femoral pulse

which description would the nurse provide the parents of an infant who are asking about what a PDA is? a) diameter of aorta is enlarged b) wall btwn R and L ventricles open c) narrowing of entrance to pulmonary artery d) connection btwn pulmonary artery and aorta

d) connection btwn pulmonary artery and aorta

which early sign of HF would the nurse recognize in an infant who has a congenital heart defect w/ L-->R shunting of blood? a) cyanosis b) restlessness c) decreased HR d) increased RR

d) increased RR lungs are stressed by pulmonary edema w/ early failure there is still adequate perfusion of blood, become fatigued, HR increases. cyanosis is a late sign of HF

which would the nurse consider the major characteristic of a cardiac malformation associated w/ L-->R shunting? a) increased Hct b) severe growth delay c) clubbing of fingers and toes d) increased blood flow to lungs

d) increased blood flow to lungs

How would the nurse describe pulmonic stenosis to the parent of a 4yr old child who was recently diagnosed? a) narrowing of valve btwn LA and LV b) hardening of valve btwn RA and RV c) hardening of valve btwn RV and arch of aorta d) narrowing of valve btwn RV and pulmonary artery

d) narrowing of valve btwn RV and pulmonary artery

Which assessment finding indicates a need to activate the rapid response team when the nurse is caring for a diabetic client w/ a bacterial infection of the foot? a) hypertonic bowel sounds in all 4 quadrants b) blood glucose lvl 145 mg/dL c) client report of lvl 9 pain of foot d) systolic BP persistently 85-90 mmHg

d) systolic BP persistently 85-90 mmHg indicates possible sepsis and SIRS

Define shock

syndrome that results from inadequate oxygen delivery to meet metabolic demands