CARDIAC
A 12-year-old with rheumatic fever has a history of long-term aspirin use. Which client statement most indicates that the client is experiencing a serious adverse reaction to aspirin? 1. "I hear ringing in my ears." 2. "I put lotion on my itchy skin." 3. "My stomach hurts after I take that medicine." 4. "These pills make me cough."
1. Tinnitus is an adverse effect of prolonged aspirin therapy, and the child should be examined by a healthcare provider (HCP) for hearing loss. Itchy skin commonly accompanies the rash associated with rheumatic fever, and the nurse can encourage lotion use. The nurse teaches clients to take aspirin with food or milk to avoid abdominal discomfort. The nurse can also address the fact that coughing after ingesting aspirin can be caused by inadequate fluid intake during administration.
The nurse is performing the initial assessment of a child newly diagnosed Kawasaki disease. Which symptoms would the nurse expect to assess with this child? 1. Dry, swollen, fissured lips 2. Non-palpable lymph nodes 3. Conjunctivitis with exudates 4. Cyanosis of the hands and feet
1: Dry, swollen, fissured lips are symptoms of Kawasaki disease. Lymph nodes can be palpable, conjunctivitis is present but without exudates, and hands and feet are typically erythematous.
An infant with tetralogy of Fallot is having a hypercyanotic episode ("tet" spell). Which nursing interventions are appropriate for the nurse to implement for this infant? Standard Text: Select all that apply. 1. Place the child in knee-chest position. 2. Draw blood for a serum hemoglobin. 3. Administer oxygen. 4. Administer morphine and propranolol intravenously as ordered. 5. Administer Benadryl as ordered.
1, 3, 4: : When an infant with tetralogy of Fallot has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities), and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). The nurse would not draw blood until the episode had subsided, because unpleasant procedures are postponed. Benadryl is not appropriate for this child. : When an infant with tetralogy of Fallot has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities), and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). The nurse would not draw blood until the episode had subsided, because unpleasant procedures are postponed. Benadryl is not appropriate for this child. Rationale 4: When an infant with tetralogy of Fallot has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities), and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). The nurse would not draw blood until the episode had subsided, because unpleasant procedures are postponed. Benadryl is not appropriate for this child.
Which signs and symptoms would lead the nurse to suspect a child has tetralogy of Fallot (TOF)? Select all that apply. 1. murmur 2. history of squatting 3. bounding pulses 4. cyanosis 5. faint pulse 6. tachypnea
1,2,4,6. TOF is a heart condition with four defects: pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta. A systolic murmur, cyanosis, and tachypnea are all symptoms of TOF. Toddlers with uncorrected defects instinctively squat (knee-chest position) to decrease the return of systemic venous blood to the heart. Coarctation of the aorta is a narrowing in the descending aorta, obstructing the systemic blood outflow. Infants with severe constriction may present with faint pulse in lower extremities and bounding pulses in upper extremities.
Discharge teaching for a 3-month-old infant with a cardiac defect who is to receive digoxin should include which information? Select all that apply. 1. Give the medication at regular intervals. 2. Mix the medication with a small volume of breast milk or formula. 3. Repeat the dose one time if the child vomits immediately after administration. 4. Notify the healthcare provider (HCP) of poor feeding or vomiting. 5. Make up any missed doses as soon as realized. 6. Notify the HCP if more than two consecutive doses are missed.
1,4,6. To achieve optimal therapeutic levels, digoxin should be given at regular intervals without variation, usually every 12 hours. Vomiting and poor feeding are signs of toxicity. If more than two consecutive doses are missed, interventions may be needed to assure therapeutic drug levels. The medication should not be mixed with any other fluid as refusal may result in inaccurate intake of the medication. Taking makeup doses, or taking the medication at times other than scheduled, may adversely affect serum levels.
As part of the preoperative teaching for the family of a child undergoing a tetralogy of Fallot repair, the nurse tells the family upon returning to the pediatric floor that the child may: 1. be placed on a reduced sodium diet. 2. have an activity restriction for several days. 3. be assigned to an isolation room. 4. have visits limited to a select few.
1. Because of the hemodynamic changes that occur with open heart surgery repair, particularly with septal defects, transient congestive heart failure may develop. Therefore, the child's sodium intake typically is restricted to 2 to 3 g/day. Activity restrictions are inappropriate. Typically, the child is encouraged to walk the halls and unit. Risk for infection after the repair is the same as any postoperative client; therefore, isolation is not necessary. The child may be placed in a room with other children who are not contagious. Visitors are not restricted unless the pediatric unit has restrictive visiting policies.
A child has had open heart surgery to repair a tetralogy of Fallot with a patch. The nurse should instruct the parents to: 1. notify all healthcare providers (HCPs) before invasive procedures for the next 6 months. 2. maintain adequate hydration of at least 10 glasses of water a day. 3. provide for frequent rest periods and naps during the first 4 weeks. 4. restrict the ingestion of bananas and citrus fruit.
1. Children who have undergone open heart surgery with a patch are at risk for infection, especially subacute bacterial endocarditis (SBE), for the first 6 months following surgery. The newest evidence-based guidelines suggest that once the patch has epithelialized, these precautions are no longer necessary. Therefore, parents are instructed about SBE precautions including the need to notify providers before invasive procedures so antibiotics can be prescribed for that time period. Having the child drink a very large amount of water may lead to fluid overload. Children gear their rest schedule to their activities making it unnecessary to schedule frequent rest periods. Bananas and citrus fruit are high in potassium, but there is no evidence provided that the child has an elevated serum potassium requiring restriction.
An 18-month-old with a congenital heart defect is to receive digoxin twice a day. Which instructions should the nurse give the parents? 1. Digoxin enables the heart to pump more effectively with a slower and more regular rhythm. 2. Signs of toxicity include increased pulse and visual disturbances. 3. Digoxin is absorbed better if taken with meals. 4. If the child vomits within 15 minutes of administration, the dosage should be repeated.
1. Digoxin's effect is to slow the rate of the electrical conduction through the heart and increase the strength of the heart's contraction. Signs of toxicity include anorexia and decreased heart rate, not visual changes or increases in heart rate. Digoxin should be taken 1 hour before meals or 2 hours after meals in order to obtain better absorption of the drug. If the child vomits within 15 minutes of administration, the dose should not be repeated because it is not known how much of the medication has been absorbed.
Which initial physical finding indicates the development of carditis in a child with rheumatic fever? 1. heart murmur 2. low blood pressure 3. irregular pulse 4. anterior chest wall pain
1. In rheumatic fever, the connective tissue of the heart becomes inflamed, leading to carditis. The most common signs of carditis are heart murmurs, tachycardia during rest, cardiac enlargement, and changes in the electrical conductivity of the heart. Heart murmurs are present in about 75% of all clients during the first week of carditis and in 85% of clients by the third week. Signs of carditis do not include hypotension or chest pain. The client may have a rapid pulse, but it is usually not irregular.
The nurse has admitted a child with tricuspid atresia. The nurse would expect which initial lab result? 1. A high hemoglobin 2. A low hematocrit 3. A high white blood cell count 4. A low platelet count
1. The child's bone marrow responds to chronic hypoxemia by producing more red blood cells to increase the amount of hemoglobin available to carry oxygen to the tissues. This occurs in cases of cyanotic heart defects such as tricuspid atresia. Therefore, the hematocrit would not be low, the white blood cell count would not be high (unless an infection were present), and the platelets would be normal.
A 13-year-old has been admitted with a diagnosis of rheumatic fever and is on bed rest. He has a sore throat. His joints are painful and swollen. He has a red rash on his trunk and is experiencing aimless movements of his extremities. Use the chart below to determine what the nurse should do first. 1. Report the heart rate to the healthcare provider (HCP). 2. Apply lotion to the rash. 3. Splint the joints to relieve the pain. 4. Request a prescription for medication to treat the elevated temperature.
1. The child's heart rate of 150 bpm is significantly above its rate at the time of his admission. The nurse must notify the HCP . The increase in heart rate may indicate carditis, a possible complication of rheumatic fever that can cause serious and lifelong effects on the heart. The HCP will intervene with medication and cardiac monitoring. While lotion may provide comfort, the most important action for the nurse is to notify the HCP of the increased heart rate. Splinting will not help the inflammation that is causing the painful joints. The joint pain will migrate and subside with time. The temperature is not elevated at this time and does not require intervention.
The nurse admits a child with a ventricular septal defect (VSD) to the unit. Which nursing diagnosis for this child is the most appropriate? 1. Impaired Gas Exchange Related to Pulmonary Congestion Secondary to the Increased Pulmonary Blood Flow 2. Deficient Fluid Volume Related to Hyperthermia Secondary to the Congenital Heart Defect 3. Acute Pain Related to the Effects of a Congenital Heart Defect 4. Hypothermia Related to Decreased Metabolic State
1: Because of the increased pulmonary congestion, Impaired Gas Exchange would be an appropriate nursing diagnosis. Ventricular septal defects do not cause pain, fever, or deficient fluid volume.
The mother of a child with a heart defect is questioning the nurse about the child's diuretic. When teaching the mother about the medication, what should the emphasis from the nurse? 1. Close monitoring of output 2. The digitalization process 3. The possibility that pulses in the child might be weak 4. The child's increased appetite
1: It is important to monitor the output of the child on a diuretic to determine effectiveness of the drug. Digitalization pulses are not associated with diuretics. The child will usually have a decreased appetite.
The nurse is admitting an infant diagnosed with supraventricular tachycardia. Which intervention is the priority for this infant? 1. Apply ice to the face. 2. Perform Valsalva's maneuver. 3. Administer a beta blocker. 4. Prepare for cardioversion.
1: Supraventricular tachycardia episodes are initially treated with vagal maneuvers to slow the heart rate when the infant is stable. In stable infants, the application of ice or iced saline solution to the face can reduce the heart rate. The infant is not capable of performing Valsalva's maneuver. Calcium channel blockers, not beta blockers, are the drugs of choice. Cardioversion is used in an urgent situation, but is not typically the initial treatment.
A child has been admitted to the hospital unit in congestive heart failure (CHF). Which symptom would the nurse anticipate upon assessment of the child? 1. Weight loss 2. Bradycardia 3. Tachycardia 4. Increased blood pressure
3: Tachycardia is a sign of congestive heart failure because the heart attempts to improve cardiac output by beating faster. Bradycardia is a serious sign and can indicate impending cardiac arrest. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases because of retention of fluids.
The nurse is preparing to discharge an infant with a congenital heart defect. The infant will be cared for at home by the parents until surgery. Which items will the nurse include in the discharge teaching for this infant and family? Standard Text: Select all that apply. 1. Allow the infant to feed for 60 minutes. 2. Hold the infant at a 45 degree angle. 3. Encourage frequent hand hygiene. 4. Notify the health care provider for fever. 5. Pump the breasts and feed with a bottle if weight gain is an issue.
2, 3, 4, 5: Children are often managed at home until surgery. The parents should hold the infant at a 45 degree angle to decrease tachypnea. The parents should also encourage frequent hand hygiene to decrease the risk of infection. It is important to notify the health care provider for a fever, as the infant will be at risk for dehydration and digoxin toxicity. If the mother is breastfeeding and the infant is losing weight, the mother should
A child with Kawasaki disease is receiving low-dose aspirin. The mother calls the clinic and states that the child has been exposed to influenza. Which recommendations should the nurse make? Select all that apply. 1. Increase fluid intake. 2. Stop the aspirin. 3. Keep the child home from school. 4. Watch for fever. 5. Weigh the child daily.
2,4. Aspirin needs to be stopped because of its possible link to Reye syndrome. Additionally, the parents need to watch for signs and symptoms of influenza. Children with influenza frequently present with fever, cold symptoms, and gastrointestinal symptoms. Increasing the child's fluid intake and weighing the child daily are not needed at this time because the child is not displaying signs of influenza. Keeping the child home from school is not necessary because the child is not symptomatic and has already been exposed.
The parent of a child hospitalized with tetralogy of Fallot tells the nurse that the child's 3-year-old sibling has become quiet and shy and demonstrates more than a usual amount of genital curiosity since this child's hospitalization. The nurse should tell the parent: 1. "This behavior is very typical for a 3-year-old." 2. "This may be how your child expresses feeling a need for attention." 3. "This may be an indication that your child may have been sexually abused." 4. "This may be a sign of depression in your child."
2. According to Erikson, the central psychosocial task of a preschooler is to develop a sense of initiative versus guilt. Any environmental situation may affect the child. In this situation, the sibling is probably feeling less attention from the mother and trying to resolve the conflict in an inappropriate way. Three-year-olds are usually active and outgoing. These behaviors represent a change. Data are not sufficient to suggest the child has been exposed to a sexual experience. Symptoms of depression would include withdrawal and fatigue.
The healthcare provider (HCP) prescribes pulse assessments through the night for a 12-year-old child with rheumatic fever who has a daytime heart rate of 120 bpm. The nurse explains to the mother that this is to evaluate if the elevated heart rate is caused by: 1. the morning digitalis. 2. normal activity during waking hours. 3. a warmer daytime environment. 4. normal variations in day and evening hours.
2. An above-average pulse rate that is out of proportion to the degree of activity is an early sign of heart failure in a client with rheumatic fever. The sleeping pulse is used to determine whether the mild tachycardia persists during sleep (inactivity) or whether it is a result of daytime activities. The environmental temperature would need to be quite warmer before it could influence the heart rate. Digitalis lowers the heart rate, so the rate would be decreased during the daytime.
When developing the plan of care for a newly admitted 2-year-old child with the diagnosis of Kawasaki disease (KD), which intervention should be the priority? 1. taking vital signs every 6 hours 2. monitoring intake and output every hour 3. minimizing skin discomfort 4. providing passive range-of-motion exercises
2. Cardiac status must be monitored carefully in the initial phase of KD because the child is at high risk for congestive heart failure (CHF). Therefore, the nurse needs to assess the child frequently for signs of CHF, which would include respiratory distress and decreased urine output. Vital signs would be obtained more often than every 6 hours because of the risk of CHF. Although minimizing skin discomfort would be important, it does not take priority over monitoring the child's hourly intake and output. Passive range-of-motion exercises would be done if the child develops arthritis.
Which outcome indicates that the activity restriction necessary for a 7-year-old child with rheumatic fever during the acute phase has been effective? 1. Joints demonstrate absence of permanent injury. 2. The resting heart rate is between 60 and 100 bpm. 3. The child exhibits a decrease in chorea movements. 4. The subcutaneous nodules over the joints are no longer palpable.
2. During the acute phase of rheumatic fever, the heart is inflamed and every effort is made to reduce the work of the heart. Bed rest with limited activity is necessary to prevent heart failure. Therefore, the most reliable indicator that activity restriction has been effective is a resting heart rate between 60 and 100 bpm, normal for a 7-year-old child. No permanent damage to the joints occurs with rheumatic fever. The chorea movements associated with rheumatic fever are self-limited and usually disappear in 1 to 3 months. They are unrelated to activity restrictions. Subcutaneous nodules that occur over joint surfaces also resolve over time with no treatment. Therefore, they are not appropriate for evaluating the effectiveness of activity restrictions.
When teaching the parents of a child with a ventricular septal defect who is scheduled for a cardiac catheterization, the nurse explains that this procedure involves the use of which technique? 1. ultra-high-frequency sound waves 2. catheter placed in the right femoral vein 3. cutdown procedure to place a catheter 4. general anesthesia
2. In children, cardiac catheterization usually involves a right-sided approach because septal defects permit entry into the left side of the heart. The catheter is usually inserted into the femoral vein through a percutaneous puncture. A cutdown procedure is rarely used. Echocardiography involves the use of ultra-high-frequency sound waves. The catheterization is usually performed under local, not general, anesthesia with sedation.
A 4-year-old has been scheduled for a cardiac catheterization. To help prepare the family, the nurse should: 1. advise the family to bring the child to the hospital for a tour a week in advance. 2. explain that the child will need a large bandage after the procedure. 3. discourage bringing favorite toys that might become associated with pain. 4. explain that the child may get up as soon as the vital signs are stable.
2. The catheter insertion site will be covered with a bandage. This is important for preschool children to know as they are very concerned about bodily harm. The best time to prepare a preschool child for an invasive procedure is the night before. Bringing a favorite toy to the hospital will help decrease the child's anxiety. To prevent bleeding, the child will be expected to keep the extremity straight for 4 to 6 hours after the procedure, either in bed or on the parent's lap.
After surgery to correct a tetralogy of Fallot, the child's parents express concern to the nurse that their 4-year-old child wants to be held more frequently than usual. The nurse recommends: 1. introducing a new skill. 2. play therapy. 3. encouraging the behavior. 4. having the volunteer hold the child.
2. The child is exhibiting regression. During periods of stress, children frequently revert to behaviors that were comforting in earlier developmental stages; play therapy is one way to help the child cope with the stress. Teaching a new skill most likely would add more stress. Parents should be instructed to praise positive behaviors and ignore regressive behaviors rather than calling attention to them through encouragement or discouragement. Having someone else hold the child does not encourage coping with the stress or promoting appropriate development.
Which information should the nurse include when completing discharge instructions for the parents of a 12-month-old child diagnosed with Kawasaki disease (KD) and being discharged home? 1. Offer the child extra fluids every 2 hours for 2 weeks. 2. Take the child's temperature daily for several days. 3. Check the child's blood pressure daily until the follow-up appointment. 4. Call the healthcare provider (HCP) if the irritability lasts for 2 more weeks.
2. The child's temperature should be taken daily for several days after discharge because recurrent fever may develop. Offering the child fluids every 2 hours is not necessary. Doing so increases the child's risk for CHF. Checking the child's blood pressure at home usually is not included as part of the discharge instructions because by the time of discharge the child is considered stable and the risk for cardiac problems is minimal. Most children with KD recover fully. Irritability may last for 2 months after discharge.
An infant weighing 9 kg is in the pediatric intensive care unit following arterial switch surgery. In the past hour, the infant has had 16 mL of urine output. Which action should the nurse take? 1. Notify the healthcare provider (HCP) immediately. 2. Record the urine output in the medical record. 3. Administer a fluid bolus immediately. 4. Assess for other signs of hypervolemia.
2. Urine output for an infant weighing 9 kg should be 1 mL/kg/h. Sixteen milliliters of urine output is more than adequate for 1 hour, so the nurse should record the output in the medical record . There is no reason to notify the HCP regarding adequate urine output. The infant has adequate output, so there is no need for a fluid bolus. A fluid bolus could also cause the infant to become fluid overloaded, increasing the workload on the heart. There is no information in the question indicating that the child is hypervolemic.
When assessing a child after heart surgery to correct tetralogy of Fallot, which finding should alert the nurse to suspect a low cardiac output? 1. bounding pulses and mottled skin 2. altered level of consciousness and thready pulse 3. capillary refill of 2 seconds and blood pressure of 96/67 mm Hg 4. extremities warm to the touch and pale skin
2. With a low cardiac output and subsequent poor tissue perfusion, signs and symptoms would include pale, cool extremities; cyanosis; weak, thready pulses; delayed capillary refill; and decrease in level of consciousness.
The nurse is teaching the parents of a group of cardiac patients. Which teaching guideline will the nurse include for any child who has undergone cardiac surgery? 1. The child should be restricted from most play activities. 2. The child should be evaluated to determine if prophylactic antibiotics for dental, oral, or upper-respiratory-tract procedures are necessary. 3. The child should not receive routine immunizations. 4. The child can be expected to have a fever for several weeks following the surgery.
2: Parents should be taught that the child may need prophylactic antibiotics for some dental procedures, according to the American Heart Association, to prevent endocarditis. The child should live a normal and active life following repair of a cardiac defect. Immunizations should be provided according to the schedule, and any unexplained fever should be reported.
When teaching a preschool-age child how to perform coughing and deep-breathing exercises before corrective surgery for tetralogy of Fallot, which teaching and learning principles should the nurse address first? 1. organizing information to be taught in a logical sequence 2. arranging to use actual equipment for demonstrations 3. building the teaching on the child's current level of knowledge 4. presenting the information in order from simplest to most complex
3. Before developing any teaching program for a child, the nurse's first step is to assess the child to determine what is already known. Most older preschool children have some understanding of a condition present since birth. However, the child's interest will soon be lost if familiar material is repeated too often. The nurse can then organize the information in a sequence because there are several steps to be demonstrated. These exercises do not require the use of equipment. The nurse should judge the amount and complexity of the information to be provided, based on the child's current knowledge and response to teaching.
The nurse caring for a 7-year-old child who has undergone a cardiac catheterization 2 hours ago finds the dressing and bed saturated with blood. The nurse should first: 1. assess the vital signs. 2. reinforce the dressing. 3. apply pressure just above the catheter insertion site. 4. notify the healthcare provider (HCP).
3. Direct pressure is the first measure that should be used to control bleeding. Taking the vital signs will not control the bleeding. This should be done while another person is being sent to notify the HCP . The dressing can be reinforced after the bleeding has been contained.
A 16-month-old child diagnosed with Kawasaki disease (KD) is very irritable, refuses to eat, and exhibits peeling skin on the hands and feet. What should the nurse do first? 1. Apply lotion to the hands and feet. 2. Offer foods the toddler likes. 3. Place the toddler in a quiet environment. 4. Encourage the parents to get some rest.
3. One of the characteristics of children with KD is irritability. They are often inconsolable. Placing the child in a quiet environment may help quiet the child and reduce the workload of the heart. Although peeling of the skin occurs with KD, the child's irritability takes priority over applying lotion to the hands and feet. Children with KD usually are not hungry and do not eat well regardless of what is served. There is no indication that the parents need rest. Additionally, in this situation, the child takes priority over the parents.
When developing the discharge teaching plan for the parents of a child who has undergone a cardiac catheterization for ventricular septal defect, which information should the nurse expect to include? 1. restriction of the child's activities for the next 3 weeks 2. use of sponge baths until the stitches are removed 3. use of prophylactic antibiotics before receiving any dental work 4. maintenance of a pressure dressing until a return visit with the healthcare provider (HCP)
3. Prophylactic antibiotics are suggested for children with heart defects before dental work is done to reduce the risk of bacterial infection. Typically, activities are not restricted after a cardiac catheterization. A percutaneous approach is used to insert the catheter, so stitches are not necessary. Showering or bathing is allowed as usual. The pressure dressing will be removed before the child is discharged.
The nurse is caring for a newborn with a large ventricular septal defect. The client has undergone pulmonary artery banding. Which assessment findings indicate that the pulmonary artery band is functioning effectively? 1. Capillary refill is less than 3 seconds. 2. Urine output is greater than 1 mL/kg/h. 3. Breath sounds are clear and equal bilaterally. 4. Radial pulses are bounding.
3. Pulmonary artery banding is a palliative treatment used in pediatric clients with congenital cardiac defects with increased pulmonary blood flow. The pulmonary artery band reduces excessive pulmonary blood flow and protects the lungs from irreversible damage. When the pulmonary artery band is functioning properly, the lungs should no longer be receiving an increased amount of blood flow, which would be reflected in clear and equal breath sounds. A capillary refill of less than 3 seconds and a urine output greater than 1 mL/kg/h reflect adequate peripheral perfusion. Bounding radial pulses suggest increased pulmonary blood flow.
A nurse is planning care for a 12-year-old with rheumatic fever. The nurse should teach the parents to: 1. observe the child closely. 2. allow the child to participate in activities that will not tire him. 3. provide for adequate periods of rest between activities. 4. encourage someone in the family to be with the child 24 hours a day.
3. The nurse should teach the parents to provide for sufficient periods of rest to decrease the client's cardiac workload. The client's condition does not warrant close observation unless cardiac complications develop. The child's activity level will be based on the results of the sedimentation rate, c-reactive protein, heart rate, and cardiac function. The family does not need to be with the client 24 hours a day unless carditis develops and his condition deteriorates.
Which action should the nurse perform to help alleviate a child's joint pain associated with rheumatic fever? 1. Maintain the joints in an extended position. 2. Apply gentle traction to the child's affected joints. 3. Support proper alignment with rolled pillows. 4. Use a bed cradle to avoid the weight of bed linens on joints.
4. For a child with arthritis associated with rheumatic fever, the joints are usually so tender that even the weight of bed linens can cause pain. Use of a bed cradle is recommended to help remove the weight of the linens on painful joints. Joints need to be maintained in good alignment, not positioned in extension, to ensure that they remain functional. Applying gentle traction to the joints is not recommended because traction is usually used to relieve muscle spasms, not typically associated with rheumatic fever. Supporting the body in good alignment and changing the client's position are recommended, but these measures are not likely to relieve pain.
Which intervention is the greatest priority for the therapeutic management of a child with congestive heart failure (CHF) caused by pulmonary stenosis? 1. educating the family about the signs and symptoms of infection 2. administering enoxaparin to improve left ventricular contractility 3. assessing heart rate and blood pressure every 2 hours 4. administrating furosemide to decrease systemic venous congestion
4. Pulmonary stenosis can cause right-sided CHF, resulting in venous congestion. Removing accumulated fluid is a primary goal of treatment in right-sided CHF. Furosemide is used to reduce venous congestion. It is important to educate the family about signs and symptoms of CHF, but treating the client's CHF is the priority. Enoxaparin is an anticoagulant and will not help improve left ventricular contractility. It is important to assess vital signs frequently in the child with CHF, but assessments do not treat the problem.
A child diagnosed with tetralogy of Fallot becomes upset, cries, and thrashes around when a blood specimen is obtained. The child becomes cyanotic, and the respiratory rate increases to 44 breaths/min. Which action should the nurse do first? 1. Obtain a prescription for sedation for the child. 2. Assess for an irregular heart rate and rhythm. 3. Explain to the child that it will only hurt for a short time. 4. Place the child in a knee-to-chest position.
4. The child is experiencing tet or hypoxic episode. Therefore, the nurse should place the child in a knee-to-chest position. Flexing the legs reduces venous flow of blood from the lower extremities and reduces the volume of blood being shunted through the interventricular septal defect and the overriding aorta in the child with tetralogy of Fallot. As a result, the blood then entering the systemic circulation has higher oxygen content, and dyspnea is reduced. Flexing the legs also increases vascular resistance and pressure in the left ventricle. An infant often assumes a knee-to-chest position in the crib, or the mother learns to put the infant over her shoulder while holding the child in a knee-to-chest position to relieve dyspnea. If this position is ineffective, then the child may need a sedative. Once the child is in the position, the nurse may assess for an irregular heart rate and rhythm. Explaining to the child that it will only hurt for a short time does nothing to alleviate the hypoxia.
A toddler is started on digoxin (Lanoxin) for cardiac failure. Which is the initial symptom the nurse would assess if the child develops digoxin (Lanoxin) toxicity? 1. Lowered blood pressure 2. Tinnitus 3. Ataxia 4. A change in heart rhythm
4: An early sign of digoxin (Lanoxin) toxicity is a change in heart rhythm. Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in the ears), or ataxia (unsteady gait).
The nurse finds that an infant has stronger pulses in the upper extremities than in the lower extremities, and higher blood pressure readings in the arms than in the legs. Which assessment will the nurse perform next on this infant? 1. Pedal pulses 2. Pulse oximetry level 3. Hemoglobin and hematocrit values 4. Blood pressure of the four extremities
4: Coarctation of the aorta can present with stronger pulses in the upper extremities than in the lower extremities and higher blood pressure readings in the arms than in the legs because of obstruction of circulation to the lower extremities. Blood pressure values of the four limbs should be the next assessment data collected. Pedal pulses, pulse oximetry, and labs themselves will not provide the data needed.
The nurse is checking peripheral perfusion to a child's extremity following a cardiac catheterization. Which assessment finding indicates adequate peripheral circulation to the affected extremity? 1. A capillary refill of greater than three seconds 2. A palpable dorsalis pedis pulse but a weak posterior tibial pulse 3. A decrease in sensation with a weakened dorsalis pedis pulse 4. A capillary refill of less than three seconds with palpable warmth
4: The nurse checks the extremity to determine adequacy of circulation following a cardiac catheterization. An extremity that is warm with capillary refill of less than three seconds has adequate circulation. Other indicators of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate sensation, and pinkness of skin color. If the capillary refill is over three seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation may not be adequate.