Peds Test 2 - Sherpath

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While inspecting the thorax of a 3-year-old child, the nurse notes an increased respiratory rate and retractions while the child is supine on the examining table. Which action can the nurse perform next to obtain an accurate respiratory assessment? 1.Reposition the child upright. 2.Begin auscultating the lungs. 3.Ask the child to blow a tissue. 4.Allow the child to hold the stethoscope.

1. 1.Reposition the child upright. Positioning the child upright (a position of comfort) can assist with auscultation of the lungs, which is the next step of the assessment for a child with signs of respiratory distress, and can facilitate precise respiratory assessment findings. 2.Begin auscultating the lungs. Beginning auscultation of the lungs on a supine child with respiratory distress is not the next best action to obtain a precise respiratory assessment. 3.Ask the child to blow a tissue. Asking the child to blow on a tissue will help accentuate end-expiratory sounds, but it is not the next best action to obtain a precise respiratory assessment. 4.Allow the child to hold the stethoscope. Allowing the child to hold a stethoscope can help decrease anxiety, but it is not the next best action to obtain a precise respiratory assessment.

Which diagnostic test should be most efficient for evaluating an active child who has cardiac symptoms that do not currently interfere with daily activities? 1. Holter monitor 2. Chest radiography 3. Ventilation - perfusion scan 4. MRI

1 1. Holter monitor The Holter monitor continuously records heart rate and rhythm. A diary is kept to track correlations between symptoms and activities. The child remains active and data is collected during a variety of daily activities. 2. Chest radiography Chest radiography would provide an image of the heart and structures in the chest cavity but would not provide physiological information. 3. Ventilation-perfusion scan A ventilation-perfusion scan is used to determine pulmonary blood flow. Since the child's cardiac symptoms do not profoundly interfere with daily activities, this would not be the immediate choice for diagnostic testing. 4.Magnetic resonance imaging (MRI) MRI provides great detail about heart structures and valve function. The child must lie still for up to an hour or will require sedation. Other diagnostic tests can be used before performing the MRI since the child's cardiac symptoms do not profoundly interfere with daily activities.

A neonate has cyanosis and increased pulmonary blood flow. The family is confused about how increased blood flow to the lungs would decrease oxygen levels in the body. What can the nurse say to explain this pathophysiology? 1. Anatomical features present in this child prevent blood from becoming fully loaded with oxygen in the lungs before going out to the body. The body appears cyanotic due to the lower than normal oxygen levels. 2. Anatomical features present in this child increase pulmonary blood flow and oxygenation in the lungs. The oxygen is quickly used by the overworking left ventricle; this leads to decreased oxygen delivery to the body. 3. Anatomical features present in this child decrease the rate at which blood moves through the lungs. There is an increased volume of blood but it is moving slowly. This allows the lungs to use the oxygen it typically delivers to the blood. 4. Anatomical features present in this child cause the increase in pulmonary blood flow. As blood flow increases, gas exchange in the lungs decreases. This prevents the full amount of oxygen from binding to the red blood cells and cyanosis results.

1 1. Anatomical features present in this child prevent blood from becoming fully loaded with oxygen in the lungs before going out to the body. The body appears cyanotic due to the lower than normal oxygen levels. Truncus arteriosus, hypoplastic left heart syndrome, and transposition of the great arteries are three examples of congenital heart disease (CHD) that have cyanosis with increased pulmonary blood flow. Mixing of blood from the right and left sides prevents fully saturated blood from entering systemic circulation, therefore cyanosis is present. 2. Anatomical features present in this child increase pulmonary blood flow and oxygenation in the lungs. The oxygen is quickly used by the overworking left ventricle; this leads to decreased oxygen delivery to the body. The left ventricular chamber does not use the oxygen. The blood that supplies the cardiac muscle enters through the coronary arteries. This is not the pathophysiologic mechanism in this patient. 3. Anatomical features present in this child decrease the rate at which blood moves through the lungs. There is an increased volume of blood but it is moving slowly. This allows the lungs to use the oxygen it typically delivers to the blood. The rate of the blood moving through the lungs can change the oxygenation; however, blood moving slowly through the lungs would not lose its oxygen to the lungs for use. 4. Anatomical features present in this child cause the increase in pulmonary blood flow. As blood flow increases, gas exchange in the lungs decreases. This prevents the full amount of oxygen from binding to the red blood cells and cyanosis results. The increase in blood flow would not alter gas exchange mechanisms in the lungs.

What is a major concern associated with transposition of the great vessels when the patient has patent ductus arteriosus (PDA) but no additional septal defect? 1. Limited areas for mixing of blood 2. Limited delivery of blood to lungs 3. Limited oxygenation of blood sent to lungs 4. Limited delivery of blood to systemic circulation

1. Rationale in Sherpath: Survival depends on blood mixing through patent foramen ovale/ASD and patent ductus arteriosus or VSD 1. Limited areas for mixing of blood Patient relies on the mixing of blood through the fetal structures (and a septal defect), if present. 2. Limited delivery of blood to lungs Blood volume to pulmonary circulation should not be limited. Desaturated blood returns to RA, flows into RV, and out aorta to systemic circulation; saturated blood returns to LV and out pulmonary artery to lungs. 3. Limited oxygenation of blood sent to lungs Blood sent to lungs would experience normal diffusion for oxygen exchange. 4. Limited delivery of blood to systemic circulation Blood volume to systemic circulation should not be limited. Desaturated blood returns to RA, flows into RV, and out aorta to systemic circulation; saturated blood returns to LV and out pulmonary artery to lungs.

A child has been diagnosed with hypoplastic left heart syndrome. Which action by the nurse will be a priority for providing long term management of this child? 1. Contact provider as surgical consult is needed 2. Ensure adequate weight gain through proper feeding 3. Administer diuretics as ordered to help control fluid overload 4. Administer digoxin as ordered and prepare to administer on long term basis

1 1. Contact provider as surgical consult is needed This child will need a surgical consult in order to be assessed for a 3 step surgical procedure called "staged palliation". This procedure is for long-term management and is meant to correct the blood flow pattern in and out of the heart and help to improve the child's blood oxygenation. 2. Ensure adequate weight gain through proper feeding Children with hypoplastic heart often have feeding difficulties and may require a feeding tube. Though this is a priority for the patient, other issues need to be addressed in providing long term care. 3. Administer diuretics as ordered to help control fluid overload Though diuretics will be administered to help reduce fluid overload in the patient, for long term management another action will be a priority at this time. 4. Administer digoxin as ordered and prepare to administer on long term basis Though digoxin may be required to help increase efficiency of cardiac output in the child, other measures must be taken to address the long term management needs of the patient.

If aortic valvular insufficiency results from infective endocarditis, which cardiac problem can result if valvular surgery is not performed? 1. Development of heart failure. 2. Development of mitral stenosis. 3. Decreased left ventricle chamber size. 4. Decreased incidence of atrial fibrillation.

1 1. Development of heart failure. Increased volume and pressure in the left ventricle leads to dilation and eventual heart failure (due to inefficient contractility; Frank-Starling mechanism). 2. Development of mitral stenosis. Mitral insufficiency would develop as the heart dilates but the patient is not more susceptible to mitral stenosis. 3.Decreased left ventricle chamber size. The left ventricle chamber size would increase rather than decrease due to aortic valvular insufficiency. 4. Decreased incidence of atrial fibrillation. The left atrium will dilate, increasing the risk of atrial fibrillation.

What statement describes the prominent concern regarding rheumatic fever with long-term health effects? 1. Rheumatic heart disease, which is the development of permanent damage to the cardiac valves. 2. Rheumatic heart disease, which is the development of chorea in female patients; Sydenham's chorea. 3. Rheumatic heart disease, which is the development of permanent damage to the joints; osteoarthritis. 4. Rheumatic heart disease, which is the development of erythema marginatum; permanent skin damage.

1 1. Rheumatic heart disease, which is the development of permanent damage to the cardiac valves. In rheumatic fever, the development of permanent damage to the cardiac valves represents the key long-term concern. 2. Rheumatic heart disease, which is the development of chorea in female patients; Sydenham's chorea. Sydenham's chorea has a longer latency period than other symptoms but eventually resolves. 4. Rheumatic heart disease, which is the development of permanent damage to the joints; osteoarthritis. In rheumatic fever, osteoarthritis is a possible long-term health effect, but it is not the prominent concern. 5. Rheumatic heart disease, which is the development of erythema marginatum; permanent skin damage. Though Erythema marginatum will affect patients with rheumatic fever, it typically does not lead to permanent skin damage.

Which component of the respiratory system contracts and flattens to cause inspiration? 1.Diaphragm 2.Alveoli 3.Trachea 4.Lungs

1 1.Diaphragm The diaphragm is a muscle of the respiratory system that contracts and flattens to increase lung volume and cause inspiration. 2.Alveoli The alveoli aid in gas exchange, but they do not contract and flatten to cause inspiration. 3.Trachea The trachea conducts air between the larynx and the lungs, but it does not contract and flatten to cause inspiration. 4.Lungs The lungs aid in gas exchange, but they do not contract and flatten to cause inspiration.

Which test is appropriate to evaluate the effectiveness of oxygen therapy in a 2-year-old child? 1.Pulse oximetry 2.Chest radiography 3.Arterial blood gas 4.Pulmonary function test

1 1.Pulse oximetry Pulse oximetry is useful to determine oxygenation status and is the most appropriate method to evaluate the effectiveness of oxygen therapy in a 2-year-old child. 2.Chest radiography Chest radiography is used to detect respiratory disease of lungs, but is not the most appropriate test to evaluate the effectiveness of oxygen therapy in a 2-year-old child. 3.Arterial blood gas Arterial blood gas values are used primarily to determine acid-base balance, not oxygen saturation, therefore would not the most appropriate test to evaluate the effectiveness of oxygen therapy in a 2-year-old child. 4.Pulmonary function test Pulmonary function tests are used to evaluate the vital capacity and expiratory flow rate, but are not the most appropriate test to evaluate the effectiveness of oxygen therapy in a 2-year-old child.

What information can be obtained by observing the integumentary system during a cardiac assessment? 1. Evidence of cyanosis 2. Evidence of decreased preload 3. Evidence of coronary artery perfusion deficits 4. Evidence of discrepancies between upper and lower extremity blood pressure (BP)

1 1. Evidence of cyanosis Cyanosis is evident upon observation of skin, mucosal membranes, conjunctiva, and nail beds. 2. Evidence of decreased preload Changes in preload cannot be assessed by observation of the integumentary system during a cardiac assessment. Preload cannot be directly measured. 3. Evidence of coronary artery perfusion deficits Coronary artery perfusion may be assessed using ventilation-perfusion scan, but cannot be assessed by observation of the integumentary system during a cardiac assessment. 4. Evidence of discrepancies between upper and lower extremity blood pressure (BP) Discrepancies between upper and lower extremity BP cannot be assessed by observation of the integumentary system during a cardiac assessment. This can only be identified by physically taking the patient's blood pressure in the two extremities.

How does the affected heart valve in a patient with infective endocarditis differ from an affected valve in a patient with rheumatic heart disease? Which patient scenarios depict the differences in clinical manifestations and pathophysiology of rheumatic heart disease and infective endocarditis? 1. A child with infectious endocarditis with a history of numerous dental caries 2. A patient with rheumatic fever who is suffering from migratory and periodic joint pain 3. A child with infection endocarditis with a recent history of an upper respiratory tract infection 4. A child with infections endocarditis with evidence of antibodies attacking the heart tissue 5. A patient with rheumatic fever, exhibiting dancelike movements making the child prone to injury

1, 2, 5 1. A child with infectious endocarditis with a history of numerous dental caries A child with numerous dental caries is at increased risk for IE and therefore this patient presentation helps to differentiate IE from rheumatic fever. 2. A patient with rheumatic fever who is suffering from migratory and periodic joint pain Migratory joint pain is an expected presentation in a child with rheumatic fever and therefore this scenario helps to differentiate rheumatic fever from the presentation seen in a patient with IE. 3. A child with infection endocarditis with a recent history of an upper respiratory tract infection The child with rheumatic fever will more likely have a history of an upper respiratory tract infection rather than the child with infectious endocarditis. Therefore, this scenario does not help to differentiate infectious endocarditis from rheumatic fever. 4. A child with infections endocarditis with evidence of antibodies attacking the heart tissue The child with rheumatic fever rather than infectious endocarditis will have a history of an immune response to heart tissue and therefore this response does not help to differentiate rheumatic fever from infectious endocarditis. 5. A patient with rheumatic fever, exhibiting dancelike movements making the child prone to injury The child with rheumatic fever may exhibit Sydenham chorea and therefore this presentation can be used to differentiate the two diseases.

In doing assessments on patients with IE and rheumatic fever, which systems will be a priority for the nurse in treating patients with both IE and rheumatic fever? 1. Respiratory system 2. Dermatologic system 3. Neurological System 4. Cardiovascular system 5. Immunological System (ESR)

1, 3,4,5 1. Respiratory system The respiratory status for any child suffering from both rheumatic fever and IE will be a priority and therefore not a priority in one disease over the other. 2. Dermatologic system The dermatological system will be more important for the assessment in children with rheumatic fever, since these children are susceptible to erythema marginatum and subcutaneous nodules and this is not a finding in children with IE. Correct 3. Neurological System In a child suffering from IE and rheumatic fever, neurological monitoring will need to be a priority since there is an increased risk for an emboli. The child with rheumatic fever will be at increased risk for seizures. Correct 4. Cardiovascular system In both diseases, serious cardiovascular manifestations can occur that make the cardiovascular assessments a priority for both patients. Correct 5. Immunological System (ESR) The immunological status of both patients will be a priority since any disease affecting a child will involve the immune system.

Which statements would a nurse use while educating a teenager recently diagnosed with HCM? 1. Limit exertion and competition sports to reduce strain on the heart 2. Strenuous exercise and no competitive sports are permitted until the HCM becomes symptomatic 3. Prophylactic epinephrine will be used to increase rate and contractility of the heart 4. Prophylactic beta blockers medicine will be used to reduce the risk of abnormal heart rhythms 5. A holter monitor will help determine if you have an abnormal heart rhythm even without symtpoms

1, 4,5, 1. Limit exertion and competitive sports to reduce strain on the heart. Restriction from strenuous exercise and competitive sports is essential to decrease the strain on the heart. 2. Strenuous exercise and no competitive sports are permitted until the HCM becomes symptomatic. Even if a patient is asymptomatic, exercise and sports are restricted. 3. Prophylactic epinephrine will be used to increase rate and contractility of the heart. Prophylactic epinephrine is not indicated. This would increase the strain on the heart. 4. Prophylactic beta blockers medicine will be used to reduce the risk of abnormal heart rhythms. Especially in asymptomatic patients with a family history of HCM, prophylactic beta blockers should be used to reduce the risk of dysrhythmia. 5. A Holter monitor will help determine if you have an abnormal heart rhythm, even without symptoms. A patient with HCM may have dysrhythmia but no symptoms. The Holter monitor will help screen to identify any dysrhythmia.

Question 18 of 19 Pulmonary arterial hypertension (PAH) management is designed to treat the symptoms of heart failure (HF). How does treating HF symptoms facilitate the management of PAH? 1. Improving right-sided heart function and fluid management will decrease the symptoms of PAH. 2. Increasing afterload will force the heart to increase contractility and therefore decrease PAH. 3. Improving left-side heart functions will increase cardiac output to systemic circulation, therefore decreasing pulmonary arterial hypertension. 4. Increasing preload will increase ventricular stretch and improve contractility (Frank-Starling Mechanism) which will overcome the afterload of the PAH.

1,2 1. Improving right-sided heart function and fluid management will decrease the symptoms of PAH. The right side of the heart cannot match the afterload of the PAH and begins to undergo fibrosis and chamber dilation. Increasing contractility will help match afterload and decrease EDV. Decreasing blood volume will also improve right-side function. 2. Increasing afterload will force the heart to increase contractility and therefore decrease PAH. PAH is the cause of increased afterload. Drugs targeting pulmonary circulation to decrease afterload can be useful. 3. Improving left-side heart functions will increase cardiac output to systemic circulation, therefore decreasing pulmonary arterial hypertension. Left-side heart function improvements will not compensate for the changes experienced on the right side. 4. Increasing preload will increase ventricular stretch and improve contractility (Frank-Starling Mechanism) which will overcome the afterload of the PAH. Increasing preload in the failing heart causes stretch beyond optimal length and decreases the force of contraction.

In doing the respiratory assessment in a patient with heart failure (HF), which assessment findings should the nurse expect to see? 1. Distinctive cough 2. Abnormal lung sounds 3. Deep breaths with activity 4. Distinctive odor on the breath 5. Increased number of respirations

1,2,3 1. Distinctive cough Patients suffering from heart failure may have an accumulation of fluid in the lungs, and a distinctive cough may be heard in doing a respiratory assessment in these patients. 2. Abnormal lung sounds If there is congestion in the lungs, this may be heard by the nurse while performing the respiratory assessment on the child. 3. Deep breaths with activity A child with heart failure will often need to take deep breaths with any sort of exertion, and this would be an expected finding in the respiratory assessment. 4. Distinctive odor on the breath Heart failure patients will not typically have an abnormal smell on their breath. If the liver is failing, along with the heart, then the nurse may find an abnormal smell. 5. Increased number of respirations Since the heart is failing, there will not be enough blood pumped to the lungs to be adequately oxygenated. The child may compensate by taking more breaths, which can be found during the respiratory assessment.

At birth, clamping of the umbilical cord and the first breath generates pressure changes in the neonate's circulation. This results in major changes in which aspects of the heart? Select all that apply. 1. Path of blood flow 2. Blood oxygenation 3. Vascular resistance 4. Right ventricle workload 5. Function of superior vena cava

1,2,3 1. Path of blood flow The pressure changes result in closure of fetal valves, altering the flow of blood. Primarily, blood will now obtain oxygen from the lungs instead of the placenta. Blood will no longer be shunted away from the liver. 2. Blood oxygenation The pressure changes result in closure of fetal valves, shifting the organ responsible for oxygenation of the blood. The lungs will now oxygenate the blood as the connection to the placenta is severed. This results in a distinct distribution of oxygenated blood so the right side of the heart contains primarily deoxygenated blood and the left side contains oxygenated. 3. Vascular resistance The pressure changes result in decrease in vascular resistance and increase in pulmonary blood flow. 4. Right ventricle workload The right ventricle does not change workload in response to closure of fetal valves. 5. Function of superior vena cava The closure of fetal valves does not affect function of superior vena cava.

Which physiologic factors must be taken into consideration when determining cardiac output? 1. Preload 2. Afterload 3. Heart rate 4. Respiratory rate 5. Oxygen saturation

1,2,3 1. Preload Preload is an important factor for determining cardiac output as it is necessary to determine stroke volume, which is used to directly calculate cardiac output. 2. Afterload Afterload is an important factor for determining cardiac output as it is necessary to determine stroke volume, which is used to directly calculate cardiac output. 3. Heart rate Heart rate is a crucial factor that contributes to the calculation of cardiac output. 4. Respiratory rate The patient's respiratory rate, while it may affect oxygen availability, does not directly impact calculation of cardiac output. 5. Oxygen saturation Oxygen saturation of the blood does not contribute to the calculation of cardiac output.

During development, pulmonary veins may aberrantly attach to the superior vena cava. What are the possible outcomes or clinical manifestations of this anomaly? Select all that apply. 1. Cyanosis 2. Tachycardia 3. Peripheral edema 4. Pulmonary hypotension 5. Mixed blood will be delivered to systemic circulation

1,2,3,5 1. Cyanosis Cyanosis will occur because oxygenated blood is not sent to systemic circulation. 2. Tachycardia Tachycardia occurs in an effort to increase cardiac output (CO) and increase oxygen delivery. 3. Peripheral edema There will be decreasing peripheral pulses that would not promote edema. 4. Pulmonary hypotension Pulmonary hypotension will not occur. Instead, pulmonary hypertension develops. 5. Mixed blood will be delivered to systemic circulation Pulmonary arteries deliver oxygenated blood to the deoxygenated right side of the heart. This causes a mixing of blood. There must be an open PDA to allow blood to flow to left side of the heart and distribute mixed blood to systemic circulation.

What physiological changes are augmented by strenuous exercise and high altitudes in the patient with pulmonary arterial hypertension (PAH)? 1. Cyanosis 2. Peripheral edema 3. Pulmonary edema 4. Right-sided heart hypertrophy 5. Increased pulmonary venous pressure

1,2,4 1. Cyanosis Patients with PAH can develop cyanosis with strenuous exercise and high altitudes as pulmonary blood flow rate may not be adequate. 2. Peripheral edema Peripheral edema is possible as the right side of the heart is volume- and pressure- overloaded. 3. Pulmonary edema Pulmonary edema is not likely because area of high pressure is the pulmonary arteries. Distal to pulmonary arteries, pressures would decrease. 4. Right-sided heart hypertrophy The right side of the heart can develop hypertrophy due to increased pressure within pulmonary arteries. 5. Increased pulmonary venous pressure The venous flow is distal to area of hypertension and should have decreased pressures.

What clinical evidence suggests carditis in a patient with suspected RF? Select all that apply. 1. Tachycardia. 2. Pericardial friction rub. 3. Development of a left-to-right shunt. 4. Development or change in cardiac murmur. 5. Fever unresponsive to antibiotic treatment.

1,2,4 Observe for signs of carditis, including tachycardia; new or changed heart murmur; pericardial friction rub; shortness of breath; or edema of the face, abdomen, or ankles.

What conclusions can be drawn regarding clinical manifestations for a patient with a left-to-right ventricular shunt and decreased pulmonary blood flow? 1. Patient may have polycythemia. 2. Patient may be hypoxemic, resulting in cyanosis. 3. Patient may have increased pulmonary pressures. 4. Patient may have increased oxygen saturation on left side of heart. 5. Patient may have increased cardiac workload and ventricular strain.

1,2,5 1. Patient may have polycythemia. Polycythemia results from decreased systemic oxygenation. The kidney responds by increased RBC production. 2. Patient may be hypoxemic, resulting in cyanosis. Decreased pulmonary blood flow and mixing of blood in the ventricles can result in hypoxemia and cyanosis. 3. Patient may have increased pulmonary pressures. Patient would have decreased pulmonary pressures due to limited pulmonary blood flow. 4. Patient may have increased oxygen saturation on left side of heart. Oxygen saturation on left side of heart would not be increased due to mixing of blood in ventricles. 5. Patient may have increased cardiac workload and ventricular strain. Cardiac workload and ventricular strain would increase due to shunting blood and lesion or malformation that limits pulmonary blood flow.

Atrial septal defects are conservatively treated as many spontaneously close. What assumptions can be made regarding the possible outcomes if the defect does not close? 1. Right-sided pressures will increase. 2. There will be increased systemic pressures. 3. Right side of heart will be volume overloaded. 4. There will be increased pulmonary blood flow. 5. There will be increased oxygen saturation on right side of the heart.

1,3,4,5 1. Right-sided pressures will increase. Volume from the high pressure, left side of the heart will create increased pressures on right side of the heart. There will be increased systemic pressures. Systemic pressures may be decreased due to shunting to right side of the heart. 2. Right side of heart will be volume overloaded. Volume from the high pressure, left side of the heart will create a volume overload of right side of the heart. 3. There will be increased pulmonary blood flow. Volume from the high pressure, left side of the heart will cause an increase in pulmonary blood flow. 4. There will be increased oxygen saturation on right side of the heart. Volume from highly saturated, left side of the heart will mix with deoxygenated blood on the right side. This will increase oxygen saturation on right side of the heart.

In response to the pathophysiology of heart failure (HF), there is activation of the sympathetic nervous system and the release of hormones in an effort to maintain cardiac output (CO). How do these two systems synergistically increase cardiac output? 1. Sympathetic nervous system activity increases heart rate. 2. Sympathetic nervous system activity increases stroke volume. 3. Sympathetic nervous system activity initiates vasodilation in most of the peripheral vasculature. 4. Endocrine function of hormones from the heart, such as atrial naturietic peptide, work to increase blood volume. 5. Endocrine function of the hormones of renin-angiotensin-aldosterone-system (RAAS) leads to increased intravascular volume.

1,2,5 1. Sympathetic nervous system activity increases heart rate. Sympathetic outflow increases heart rate which increases CO. 2. Sympathetic nervous system activity increases stroke volume. Sympathetic outflow increases stroke volume which increases CO. 3. Sympathetic nervous system activity initiates vasodilation in most of the peripheral vasculature. Sympathetic outflow increases vasoconstriction in the periphery. 4. Endocrine function of hormones from the heart, such as atrial naturietic peptide, work to increase blood volume. ANP, atrial naturietic peptide is released in response to increased stretch of the myocardium. Rather than increasing blood volume, ANP decreases sodium reabsorption and increases water loss which can decrease CO. 5. Endocrine function of the hormones of renin-angiotensin-aldosterone-system (RAAS) leads to increased intravascular volume. In response to low blood volume and low blood pressure, the RAAS system works to increase sodium and water reabsorption in the kidney to increase blood volume and increase CO.

What is the relationship between the formation of vegetation on the cardiac valves and neurological symptoms in the patient with infective endocarditis? 1. Part of the vegetation can break free becoming an embolus. 2. Bacteria can release a neuronal specific toxin that leads to neuron cell death. 3. The vegetation can limit flow through a cardiac valve resulting in decreased blood flow to the brain. 4. Bacteria within the vegetation can metabolize oxygen within the blood resulting in poor oxygen saturation. 5. The fibers and bacteria that form the vegetation are made of beta amyloid peptides that can cause neurodegeneration.

1,3 1. Part of the vegetation can break free becoming an embolus. The vegetation can fragment becoming an embolus that can cause an infarct. The infarct may decrease the blood flow in and to the brain. 2. Bacteria can release a neuronal specific toxin that leads to neuron cell death. Bacteria known to cause infective endocarditis do not secrete neurotoxic agents. 3. The vegetation can limit flow through a cardiac valve resulting in decreased blood flow to the brain. The vegetation can become obstructive and limit cardiac output (E.g. vegetation on the aortic valve) decreasing blood flow to the brain. 4. Bacteria within the vegetation can metabolize oxygen within the blood resulting in poor oxygen saturation. Bacteria can be aerobic metabolizers but this would not significantly decrease oxygen saturation. 5. The fibers and bacteria that form the vegetation are made of beta amyloid peptides that can cause neurodegeneration. The vegetation forms from fibrin, platelets, and bacteria; however, amyloid beta protein is not present.

In the patient with heart failure, many organ systems will be altered. Which affected organ systems have the greatest impact on potentiating the volume overload causing heart failure (HF)? Select all that apply. 1. Renal system 2. Lymphatic system 3. Pulmonary system 4. Integumentary system 5. Gastrointestinal (GI) system

1,3 1. Renal system The renal system maintains fluid and electrolyte balance for body. When cardiac output (CO) is decreased, glomerular filtration rate (GFR) can decrease, leading to activation of renin—angiotensin—aldosterone system (RAAS). 2. Lymphatic system The lymphatic system plays passive role in reabsorption of lymph from interstitial space. It does not potentiate volume overload. 3. Pulmonary system Increased volumes and pressures in the pulmonary system can lead to pulmonary hypertension and edema. 4. Integumentary system The integumentary system does not have a role in progression of HF and volume overload. 5. Gastrointestinal (GI) system The gastrointestinal system does not have a role in progression of HF and volume overload.

What should the nurse expect to see regarding pulmonary blood flow if an infant had a ventricular left-to-right shunt? Select all that apply. 1. Pulmonary artery thickening 2. Irreversible vasoconstriction 3. Increased pulmonary blood flow 4. Pulmonary arterial hypertension (PAH) 5. Very high pulmonary vascular resistance

1,3,4 1. Pulmonary artery thickening Due to increased pressure, pulmonary artery thickening would be an expected finding in a patient with left-to-right shunt. 2. Irreversible vasoconstriction There may be vasoconstriction but in infants is usually reversible vasoconstriction. 3. Increased pulmonary blood flow Increased pulmonary blood flow would be expected in a patient with left-to-right shunt. 4. Pulmonary arterial hypertension (PAH) PAH is an expected finding in a patient with left-to-right shunt. 5. Very high pulmonary vascular resistance In children with large shunting, pulmonary vascular resistance will be lower.

Which key diagnostic findings help to differentiate infective endocarditis from rheumatic heart disease? 1. Increased ASO (antistreptolysin O) titer in rheumatic heart disease. 2. Presence of coronary artery aneurysm in infective endocarditis. 3. Bacterial (infective) endocarditis can be identified by serial blood cultures. 4. Positive throat culture for group A beta hemolytic streptococci in rheumatic fever. 5. Infective endocarditis progresses to rheumatic heart disease when erythema marginatum develops.

1,3,4 1. Increased ASO (antistreptolysin O) titer in rheumatic heart disease. Increased ASO titer reveals current or recent infection with streptococci, however, this cannot differentiate rheumatic fever from infective endocarditis alone. Both rheumatic fever and infective endocarditis can be caused by streptococcal bacteria. 2. Presence of coronary artery aneurysm in infective endocarditis. Coronary artery aneurysms are associated with Kawasaki disease, not infective endocarditis or rheumatic heart disease. 3. Bacterial (infective) endocarditis can be identified by serial blood cultures. Bacteria identified by blood culture is indicative of infective endocarditis. Bacteria in the blood helps to differentiate IE from RF. 4. Positive throat culture for group A beta hemolytic streptococci in rheumatic fever. Positive throat culture for group A beta hemolytic streptococci reveals current infection and cause of rheumatic fever. Bacterial pharyngitis is typical in RF but not IE. 5. Infective endocarditis progresses to rheumatic heart disease when erythema marginatum develops. Erythema marginatum is a sign of rheumatic fever. Infective endocarditis does not progress to become rheumatic heart disease.

1,3,4,5 1. Respiratory system The respiratory status for any child suffering from both rheumatic fever and IE will be a priority and therefore not a priority in one disease over the other. 2. Dermatologic system The dermatological system will be more important for the assessment in children with rheumatic fever, since these children are susceptible to erythema marginatum and subcutaneous nodules and this is not a finding in children with IE. 3. Neurological System In a child suffering from IE and rheumatic fever, neurological monitoring will need to be a priority since there is an increased risk for an emboli. The child with rheumatic fever will be at increased risk for seizures. 4. Cardiovascular system In both diseases, serious cardiovascular manifestations can occur that make the cardiovascular assessments a priority for both patients. 5. Immunological System (ESR) The immunological status of both patients will be a priority since any disease affecting a child will involve the immune system.

What findings during the cardiac assessment provide information about possible cardiac dysfunction? 1. Poor weight gain 2. Excessive crying 3. Decreased feeding 4. Delayed cognitive milestones 5. Respiratory pattern alterations

1,3,5 1. Poor weight gain Poor weight gain may be related to feeding difficulties or an overall increase in cardiac workload. 2. Excessive crying Although excessive crying may indicate a potential problem, it is not associated with cardiac dysfunction. 3. Decreased feeding Feeding difficulties (decreased intake or increased rest periods during feeding) can occur if the child has increased energy expenditure during feeding. This may indicate increased cardiac workload. 4. Delayed cognitive milestones Delayed cognitive milestones are not typically associated with cardiac dysfunction. Although this is a concerning finding that requires further follow-up, it does not provide more information about cardiac dysfunction. 5. Respiratory pattern alterations Altered respiratory patterns or distress are possible indicators of cardiac dysfunction.

For what reasons is it essential to assess all four extremities while performing a cardiac assessment? 1. To determine temperature differences 2. To assess the point of maximal impulse 3. To assess capillary filling in the extremities 4. To assess differences in the function of the heart valves 5. To determine differences between the central and peripheral pulses 6. To determine differences in blood pressure between upper and lower extremities

1,3,5,6 1. To determine temperature differences Temperature differences in the extremities can indicate perfusion problems. 2. To assess the point of maximal impulse The point of maximal impulse (PMI) is assessed on the chest and would not require assessment of all four extremities. 3. To assess capillary filling in the extremities Capillary filling differences in the extremities can indicate perfusion problems. 4. To assess differences in the function of the heart valves Heart valve function is evaluated by auscultation on the thorax and would not require assessment of all four extremities. 5. To determine differences between the central and peripheral pulses Pulse differences in the extremities can indicate perfusion problems. 6. To determine differences in blood pressure between upper and lower extremities BP differences in the extremities can indicate perfusion problems and cardiac disease.

How do pressures in the fetal heart and pulmonary vasculature compare to neonatal? 1. The fetal heart has lower left ventricular pressure. 2. The fetal heart has higher left ventricular pressure. 3. The pulmonary vasculature has increased pressure. 4. The fetal heart has lower right ventricular pressure. 5. The pulmonary vasculature has decreased pressure. 6. The fetal heart has higher right ventricular pressure.

1,3,6 1. The fetal heart has lower left ventricular pressure. The fetal heart has lower left ventricular pressure because it is partially bypassed due to fetal shunts that deliver blood directly to the aorta. 2. The fetal heart has higher left ventricular pressure. The fetal heart does not have higher left ventricular pressure compared to the neonate. 3. The pulmonary vasculature has increased pressure. The pulmonary vasculature has increased pressure because the lungs are not yet inflated. 4. The fetal heart has lower right ventricular pressure. The fetal heart does not have lower right ventricular pressure compared to the neonate. 5. The pulmonary vasculature has decreased pressure. The pulmonary vasculature does not have decreased pressure compared to the neonate. 6. The fetal heart has higher right ventricular pressure. The fetal heart has higher right ventricular pressure due to resistance in pulmonary trunk.

1,3,6 1. The fetal heart has lower left ventricular pressure. The fetal heart has lower left ventricular pressure because it is partially bypassed due to fetal shunts that deliver blood directly to the aorta. 2. The fetal heart has higher left ventricular pressure. The fetal heart does not have higher left ventricular pressure compared to the neonate. Correct 3. The pulmonary vasculature has increased pressure. The pulmonary vasculature has increased pressure because the lungs are not yet inflated. 4. The fetal heart has lower right ventricular pressure. The fetal heart does not have lower right ventricular pressure compared to the neonate. 5. The pulmonary vasculature has decreased pressure. The pulmonary vasculature does not have decreased pressure compared to the neonate. 6. The fetal heart has higher right ventricular pressure. The fetal heart has higher right ventricular pressure due to resistance in pulmonary trunk.

Which cardiac valve is responsible for regulating the flow of oxygenated blood between ventricle and atrium? 1. Aortic valve 2. Mitral valve 3. Tricuspid valve 4. Pulmonary valve

2 1. Aortic valve The aortic valve is responsible for regulating the flow of oxygenated blood between the left ventricle and the aorta, not the left or right atrium. 2. Mitral valve The mitral valve is responsible for regulating the flow of oxygen-rich blood from the left atrium to the left ventricle to be released into the systemic circulation. 3. Tricuspid valve The tricuspid valve is responsible for regulating the flow of deoxygenated, not oxygenated, blood between the right atrium and the right ventricle. 4. Pulmonary valve The pulmonary valve is responsible for regulating the flow of deoxygenated, not oxygenated, blood from the right ventricle to the pulmonary artery. The pulmonary valve does not regulate the flow of blood to either the right or left atrium.

The parent of a patient with aortic stenosis would like more information about a new diagnosis of pulmonary venous hypertension. What information should the nurse provide regarding treatment and outcomes? 1. Keep regular follow-up appointments for observation. 2. Increase water consumption to increase blood volume. 3. Use of vasodilators will improve both the aortic stenosis and the pulmonary venous hypertension. 4. Interventional correction of the stenotic valve will improve cardiac output and decrease the pulmonary hypertension. 5. Pay close attention to symptoms such as exercise intolerance, chest pain, dizziness, syncope, and changes in breathing patterns.

1,4 1. Keep regular follow-up appointments for observation. Keep regular appointments for observation of the aortic stenosis and progression of PAH. Changes in symptoms may require medical intervention. Athletes, depending on the severity of the stenosis and PAH, may need to limit or abstain from competitive sports. 2. Increase water consumption to increase blood volume. Increasing blood volume can worsen pulmonary venous hypertension and left-side heart function. 3. Use of vasodilators will improve both the aortic stenosis and the pulmonary venous hypertension. Vasodilators would not improve aortic stenosis. The vasodilators in the pulmonary circulation would decrease the pressure initially, but backflow from the left side of the heart will continue. 4. Interventional correction of the stenotic valve will improve cardiac output and decrease the pulmonary hypertension. Surgical valvuloplasty decreases the stenosis and improves cardiac output. 5. Pay close attention to symptoms such as exercise intolerance, chest pain, dizziness, syncope, and changes in breathing patterns. Changes in symptoms suggest changes in both the development of HF and PAH. The patient should seek immediate attention.

Following cardiac catheterization, what nursing assessments are necessary? 1. Palpate pulses 2. Percussion of the chest 3. Assess child's activity level 4. Inspect catheter insertion site 5. Assess pulmonary blood flow

1,4 1. Palpate pulses Following cardiac catheterization, distal pulses should be palpable, although they may be weaker than in the contralateral extremity. Nonpalpable distal pulses should be checked with Doppler technology. 2. Percussion of the chest Percussion of the chest has little value in cardiac assessment and it is not used to assess the patient after cardiac catheterization. 3. Assess child's activity level Activity level is not typically assessed after cardiac catheterization, as the child should be recovering in bed. 4. Inspect catheter insertion site The nurse should monitor the inspection site for bleeding and apply direct pressure for 5-10 minutes if noted. Additionally, the insertion site should be inspected for erythema and purulent drainage, indicating infection. 5. Assess pulmonary blood flow Ventilation-perfusion scan allows for assessment of pulmonary blood flow to evaluate cardiac abnormalities. It is not a nursing assessment that is necessary after cardiac catheterization.

Which statements would a nurse use while educating a teenager recently diagnosed with HCM? 1. Limit exertion and competitive sports to reduce strain on the heart. 2. Strenuous exercise and no competitive sports are permitted until the HCM becomes symptomatic. 3. Prophylactic epinephrine will be used to increase rate and contractility of the heart. 4. Prophylactic beta blockers medicine will be used to reduce the risk of abnormal heart rhythms. 5. A Holter monitor will help determine if you have an abnormal heart rhythm, even without symptoms.

1,4,5 1. Limit exertion and competitive sports to reduce strain on the heart. Restriction from strenuous exercise and competitive sports is essential to decrease the strain on the heart. 2. Strenuous exercise and no competitive sports are permitted until the HCM becomes symptomatic. Even if a patient is asymptomatic, exercise and sports are restricted. 3. Prophylactic epinephrine will be used to increase rate and contractility of the heart. Prophylactic epinephrine is not indicated. This would increase the strain on the heart. 4. Prophylactic beta blockers medicine will be used to reduce the risk of abnormal heart rhythms. Especially in asymptomatic patients with a family history of HCM, prophylactic beta blockers should be used to reduce the risk of dysrhythmia. 5. A Holter monitor will help determine if you have an abnormal heart rhythm, even without symptoms. A patient with HCM may have dysrhythmia but no symptoms. The Holter monitor will help screen to identify any dysrhythmia.

What pathophysiological changes in the patient with Kawasaki disease that increase the risk of myocardial infarction in the patient? 1. Coronary artery damage that leads to stenosis 2. Persistent vasculitis that increases cardiac workload 3. Damage to pulmonary vasculature can decrease gas exchange 4. Development of collateral coronary vessels after coronary artery injury 5. Severe thrombosis that occurs in the second stage can block coronary artery blood flow at the site of a coronary artery blood flow at the site of a coronary aneurysm

1,5 1. Coronary artery damage that leads to stenosis. Anything that can block the flow of blood in a coronary artery will cause myocardial infarction. Aneurysms can resolve into stenotic lesions in the coronary arteries and precipitate MI. 2. Persistent vasculitis that increases cardiac workload. Vasculitis may increase cardiac workload but would not increase the risk of MI. 3. Damage to pulmonary vasculature can decrease gas exchange. Decreased gas exchange will cause cyanosis and possible angina but would not increase the risk of MI. 4. Development of collateral coronary vessels after coronary artery injury. Collateral coronary vessels would decrease the risk of MI by providing circulation to the cardiac muscle through an additional vessel route. Correct 5. Severe thrombosis that occurs in the second stage can block coronary artery blood flow at the site of a coronary aneurysm. Anything that can block the flow of blood in a coronary artery will cause myocardial infarction. Severe thrombosis and development of coronary aneurysms can cause MI.

The nurse is assessing a child with a dysrhtyhmia and notes a slower than normal pulse. Which additional actions should the nurse perform to assess for possible complications of this bradydysrhythmia? 1. Measure respirations 2. Check oral temperature 3. Auscultate bowel sounds 4. Check ROM in extremities 5. Check color and skin temperature of extremities

1,5 1. Measure respirations. If a child is having a dysrhythmia, breathing must be assessed. Chest compression and ventilation are indicated if the child stops breathing. 2. Check oral temperature. Oral temperature may be used to identify infection but is not used to assess complications of dysrhythmias. 3. Auscultate bowel sounds. Bradycardia does not directly affect gastric motility; it would not be used to determine adequate perfusion. 4. Check range of motion (ROM) in extremities. ROM tests musculoskeletal function; it is not used to assess complications of dysrhythmias. 5. Check color and skin temperature of extremities. If a child is having a dysrhythmia, circulation must be assessed. If the extremities are perfused and cyanosis is not noted, that indicates adequate perfusion; however, the presence of cool and cyanotic extremities would indicate poor perfusion secondary to the abnormal rate & rhythm.

What is the function of low-dose treatment for patients recovering from KD with coronary artery involvement? 1. Low-dose aspirin treatment is used to reduce platelet aggregation. 2. Low-dose aspirin treatment is used to reduce edema. 3. Low-dose aspirin treatment is used to reduce inflammation. 4. High-dose aspirin treatment is used to reduce lymphocyte activity.

1. 1. Low-dose aspirin treatment is used to reduce platelet aggregation. Initially, high-dose aspirin therapy is used for anti-inflammatory and antipyretic effects; later, low-dose aspirin is used to limit platelet aggregation and prevent thrombi. In patients with coronary artery involvement, low-dose aspirin treatment is continued indefinitely (long term). 2. Low-dose aspirin treatment is used to reduce edema. Short-term high-dose aspirin is used to reduce edema related to inflammation. Aspirin would not be used long-term, as the question states, to reduce edema. 3. Low-dose aspirin treatment is used to reduce inflammation. Short-term high-dose aspirin, rather than low-dose aspirin is used to reduce inflammation until the fever resolves. 4. High-dose aspirin treatment is used to reduce lymphocyte activity. High-dose aspirin does not have specific action against lymphocyte activity.

During assessment, the nurse notes shortness of breath and severe chest pain in a patient with suspected Kawasaki disease. What conclusion should be drawn based on these manifestations? 1. The patient is experiencing symptoms related to myocardial infarction. 2. The patient is experiencing symptoms related to peripheral edema. 3. The patient is experiencing symptoms related to pulmonary venous hypertension. 4. The patient is experiencing symptoms related to respiratory involvement caused by Kawasaki disease.

1. 1. The patient is experiencing symptoms related to myocardial infarction. Severe thrombocytosis occurs during the subacute period and marks the period of highest risk for coronary artery thrombosis in the areas of aneurysm, resulting in myocardial infarction. 2. The patient is experiencing symptoms related to peripheral edema. Peripheral edema would be obvious in the skin assessment during cardiac exam. It would not cause shortness of breath or chest pain. 3. The patient is experiencing symptoms related to pulmonary venous hypertension. Kawasaki disease may cause respiratory symptoms caused by heart dysfunction. Pulmonary venous hypertension would occur after the left side of the heart began to fail. 4. The patient is experiencing symptoms related to respiratory involvement caused by Kawasaki disease. Kawasaki disease may have clinical manifestations related to the respiratory system but the respiratory symptoms are caused by heart dysfunction.

A child presents to the clinic suffering from Truncus Ateriosus. After the nurse administers the diuretic, which physiologic change can the nurse expect to see in the patient over the course of treatment? 1. Reduction in volume overload thereby increasing cardiac output (CO) 2. Increasing resistance in the systemic circulation thereby reducing any potential cyanotic episodes 3. Reduction in vascular resistance and therefore a decrease in the pressure in the common ventricular outflow tract 4. Reduction in blood return to the right side of the heart thereby allowing more blood to enter the common outflow tract

1. Rationale in Sherpath: Manifestations Failure to thrive Increased risk for pulmonary infections Signs of HF and cyanosis in neonate-determined by volume of pulmonary blood flow (higher the flow, greater the symptoms of HF) Pulmonary vascular disease Pulmonary stenosis limits flow and increases cyanosis Harsh systolic murmur with thrill; diastolic murmur of truncal valve insufficiency may be heard; opening of single truncal valve produces a click 1. Reduction in volume overload thereby increasing cardiac output (CO) With diuretic therapy the nurse will expect to see a reduction in volume overload in the heart, thereby improving cardiac output and lowering the risk for heart failure. 2. Increasing resistance in the systemic circulation thereby reducing any potential cyanotic episodes Though increasing resistance may be the goal for some children with cyanotic heart lesion, this does not describe the expected response with diuretic therapy. 3. Reduction in vascular resistance and therefore a decrease in the pressure in the common ventricular outflow tract With a vasodilator the nurse would expect to see a reduction in vascular resistance and therefore this is not the expected physiologic response the nurse would expect to see with diuretic therapy. 4. Reduction in blood return to the right side of the heart thereby allowing more blood to enter the common outflow tract Though a lower blood return to the right side of the heart may occur with a diuretic, a higher amount of blood entering the common outflow tract is not an expected response with diuretic therapy.

A 9-year-old child presents at the Outpatient Unit with reports of runny nose, cough, and fever for two days. Demonstrate the appropriate method of conducting respiratory assessment in this child by organizing the sequential steps listed. 1.Inspect chest configuration 2.Count respiratory rate 3.Auscultate starting in the posterior then anterior thorax 4.Palpate chest for pectus carinatum 5.Perform chest percussion

1.Inspect chest configuration 2.Count respiratory rate 3.Auscultate starting in the posterior then anterior thorax 4.Palpate chest for pectus carinatum 5.Perform chest percussion After inspecting the chest, the nurse should count the respiratory rate, auscultate lungs sounds from posterior to anterior thorax, palpate the chest, and finally percuss the chest.

Which statement explains the development of pulmonary hypertension in an infant with a large left-to-right shunting defect? 1. As a large volume of blood leaves the right ventricle and enters the pulmonary vein, this will affect the pulmonary vasculature and lead to pulmonary hypertension in the child suffering from this congenital heart lesion. 2. Any congenital shunt can increase blood volume in the heart affecting both the pulmonary vein and pulmonary artery in delivering blood to the lungs and from the lungs to the heart respectively. The pulmonary vasculature responds to this increased load by vasoconstriction leading to pulmonary hypertension. 3. When a child is suffering from a heart lesion, decreased blood flow leads to vasodilation and eventual remodeling in the pulmonary vessels. Thickened vessel walls are irreversibly vasoconstricted leading to pulmonary hypertension. 4. With left-to-right shunting there is decreased blood volume in the ventricles that can cause vasoconstriction and eventual thickening of the pulmonary vessels. This will eventually cause pulmonary hypertension and respiratory distress in the child with the congenital heart lesion.

2 1. As a large volume of blood leaves the right ventricle and enters the pulmonary vein, this will affect the pulmonary vasculature and lead to pulmonary hypertension in the child suffering from this congenital heart lesion. Blood flows from the right ventricle to the pulmonary artery rather than the pulmonary vein, and therefore this statement does not explain the development of hypertension within the pulmonary vasculature. 2. Any congenital shunt can increase blood volume in the heart affecting both the pulmonary vein and pulmonary artery in delivering blood to the lungs and from the lungs to the heart respectively. The pulmonary vasculature responds to this increased load by vasoconstriction leading to pulmonary hypertension. Any congenital heart defect that leads to fluid overload in the ventricles can affect the pulmonary vasculature. If more work is required by both the pulmonary artery and pulmonary vein, then the pulmonary vasculature will respond by vasoconstricting leading to pulmonary hypertension. This can further damage the alveoli and cause the respiratory problems often seen in children with congenital heart defects. 3. When a child is suffering from a heart lesion, decreased blood flow leads to vasodilation and eventual remodeling in the pulmonary vessels. Thickened vessel walls are irreversibly vasoconstricted leading to pulmonary hypertension. This statement does not explain the development of pulmonary hypertension in an infant with a large left-to-right shunting defect. A decreased blood volume and flow would be desirable in a child with pulmonary hypertension. 4. With left-to-right shunting there is decreased blood volume in the ventricles that can cause vasoconstriction and eventual thickening of the pulmonary vessels. This will eventually cause pulmonary hypertension and respiratory distress in the child with the congenital heart lesion. With cardiac shunting there is usually an overload of volume in the heart rather than a decreased blood volume. This statement, therefore, does not explain the development of pulmonary hypertension in a child with a cardiac shunt.

A patient with CHD is hospitalized for suspected infective endocarditis. The patient has a history of heart murmur, and during assessment an alteration in the murmur is heard. What is the nurse's priority response? 1. Document the findings. 2. Notify the health care provider. 3. Prepare the patient for an ECHO. 4. Have the patient take a deep breath, and re-listen to the heart sounds.

2 1. Document the findings. The alteration in the sound of the murmur indicates the presence of a vegetation on a cardiac valve. Though the findings will need to be documented in detail, this is not the priority response of the nurse at this time. 2. Notify the health care provider. The alteration in the sound of the murmur indicates the presence of a vegetation on a cardiac valve. The provider should be notified of the change in murmur. 3. Prepare the patient for an ECHO. The alteration in the sound of the murmur indicates the presence of a vegetation on a cardiac valve. Though an ECHO can be done, it will not be the priority response at this time. 4. Have the patient take a deep breath, and re-listen to the heart sounds.

The nurse is auscultating the chest of a pediatric patient and identifies a clear heart murmur. Palpation does not identify a thrill. The nurse should note this as which grade of murmur? 1. Grade 1 2. Grade 3 3. Grade 5 4. Grade 6

2 1. Grade 1 A grade 1 murmur is very faint and difficult to hear, even with a stethoscope. It is unlikely that the nurse would be able to clearly identify a grade 1 heart murmur through the stethoscope. 2. Grade 3 A grade 3 murmur is moderately loud using a stethoscope but is not accompanied by a palpable thrill. 3. Grade 5 The nurse would not note a grade 5 murmur as this is accompanied by a palpable thrill, which the nurse did not identify. 4. Grade 6 The nurse would not note a grade 6 murmur as this is extremely loud and accompanied by a palpable thrill, which the nurse did not identify.

The nurse is caring for a patient suffering from a cyanotic heart lesion and has just inserted an IV line. Moments later the child appears to be in moderate distress and action is required. Which clinical manifestation should require the most immediate action? 1. Increase in crying intensity 2. Changes in neurologic status 3. Alterations in blood pressure 4. Notable changes in breathing patterns

2 1. Increase in crying intensity Any increasing in crying intensity will need to be monitored by the nurse. Although any changes in crying patterns will need to be assessed, this is not the priority action in this instance. 2. Changes in neurologic status Any child with a right-to-left shunt is at increased risk of arterial and venous blood mixing. If air is introduced to an IV line, the venous blood obtaining this air can enter the arterial system and send an air embolus to the brain causing a cerebrovascular accident. This child will require immediate attention since changes in neurologic status can be evidence of a stroke. 3. Alterations in blood pressure A child suffering from a cyanotic lesion will often experience alterations in blood pressure, especially if vasoconstrictors are necessary. Though blood pressure will need to be monitored in this child, it is not the most immediate action in this situation. 4. Notable changes in breathing patterns Notable changes in breathing patterns can indicate worsening of hypoxia. Though this will need to be assessed by the nurse, there are more immediate concerns that need attention.

A newborn infant has pulmonary atresia with intact ventricular septum. The parents want to know why the health care provider said it was important to keep fetal structures open. How can the nurse explain the rationale for maintaining fetal structures in the newborn infant? 1. Maintaining open fetal structures will allow blood to bypass lungs. This will allow for use of mechanical ventilation. 2. Maintaining open fetal structures will allow blood to make its way to the lungs. This will allow for oxygenation of the blood for the baby. 3. Maintaining open fetal structures will shift pressure in the ventricles. 4. Maintaining open fetal structures will allow for reversal of blood flow in the heart and body. This will allow for oxygenation of blood from left side of the heart and right side of the heart will pump blood to body.

2 1. Maintaining open fetal structures will allow blood to bypass lungs. This will allow for use of mechanical ventilation. The open fetal structures do not cause bypass of the lungs as seen in utero. Additionally, mechanical ventilation would still rely on lungs for oxygenation. 2. Maintaining open fetal structures will allow blood to make its way to the lungs. This will allow for oxygenation of the blood for the baby. In the fetus, blood bypasses nonfunctioning lungs using ductus arteriosus and foramen ovale. Foramen ovale will continue to let deoxygenated blood move to left side of the heart. Ductus arteriosus will now have reversed flow; blood will move from aorta into ductus arteriosus and to pulmonary circulation for oxygenation of blood. Then, mixed blood can be pumped to body. 3. Maintaining open fetal structures will shift pressure in the ventricles. High pressure generated on right side of the heart will force pulmonary blood flow. Pressure in right ventricle would not increase if fetal structures remain open. Right ventricle is hypoplastic and pulmonary valve has not developed. 4. Maintaining open fetal structures will allow for reversal of blood flow in the heart and body. This will allow for oxygenation of blood from left side of the heart and right side of the heart will pump blood to body. A full reversal of blood flow in body is not possible. Open fetal structures still maintain general left-to-right movement of blood.

When caring for a child with a right-to-left shunt, what precaution is essential when obtaining IV access? 1. Carefully inspect tubing to ensure adequate pressure in the vein. 2. Use meticulous attention to avoid introducing air bubbles in tubing of IV line. 3. Use careful attention to the access site; placement in the forearm will limit accidental removal. 4. Ensure that the patient will be able to walk to limit deep vein thrombosis. Placement of the IV into a vein of the upper extremity is preferred.

2 1. Carefully inspect tubing to ensure adequate pressure in the vein. Though this will be an important precaution to take for inserting the line, other actions will be important during the IV insertion. 2. Use meticulous attention to avoid introducing air bubbles in tubing of IV line. There is an increased risk of air emboli in patients with right-to-left shunts, which can cause stroke or heart attack. 3. Use careful attention to the access site; placement in the forearm will limit accidental removal. Location of the IV access should be chosen to best suit the patient when possible, however this is not of critical importance in the child with a right-to-left shunt. 4. Ensure that the patient will be able to walk to limit deep vein thrombosis. Placement of the IV into a vein of the upper extremity is preferred. The patient with a right-to-left shunt does not need to have the ability to walk to prevent DVT.

The mother of a patient with RF asks the nurse why her child must be on antibiotics. What statement clearly explains the use of prophylactic antibiotics after rheumatic fever? 1. Decreased inflammation that is necessary to prevent further cardiac valve damage. 2. Repeated streptococcal infection can further damage the cardiac valves. Prevention is essential. 3. Prevention of platelet aggregation due to the presence of bacteria is essential. This prevents vegetation formation. 4. Suppression of the immune response is critical; antibiotics help control the immune system reaction to bacterial infection.

2 1. Decreased inflammation that is necessary to prevent further cardiac valve damage. Antibiotics do not control inflammation. 2. Repeated streptococcal infection can further damage the cardiac valves. Prevention is essential. Antibiotics help reduce the risk to subsequent streptococcal infection, therefore further damage to the cardiac valves can be prevented. 3. Prevention of platelet aggregation due to the presence of bacteria is essential. This prevents vegetation formation. Antibiotics do not prevent platelet aggregation. 4. Suppression of the immune response is critical; antibiotics help control the immune system reaction to bacterial infection. Antibiotics do not play a role in the control of the immune system.

Which manifestation may be reduced if the vasculitis of Kawasaki disease is limited? 1. Fever 2. Aneurysm 3. Beau's lines 4. Thrombosis

2 1. Fever The fever occurs before the onset of vasculitis. Therefore, reduction in vascular inflammation will not reduce the fever. 2. Aneurysm Aneurysm occurs as a result of the vasculitis associated with KD. Reducing the vascular information can decrease the development of aneurysms. 3. Beau's lines Beau's lines, which appear on the nails in the convalescent stage, are a manifestation of KD. This manifestation appears 1-2 months after the onset of the fever. Decreasing vascular inflammation will not prevent the development of Beau's lines. 4. Thrombosis Secondary thrombocytosis occurs in the second stage of Kawasaki disease. Reducing vascular inflammation does not decrease the possibility of thrombosis.

A mother is concerned that her child suffering from heart failure (HF) has started to experience abdominal pain. What explanation by the nurse can be provided to the mother to help her understand this coexisting condition? 1. Heart failure causes ischemia leading to abdominal pain. 2. Fluid overload causing congestion can lead to abdominal pain. 3. H. pylori infections often occur in heart failure patients causing abdominal pain. 4. Heart failure can lead to increased secretion of abdominal acids therefore causing stomach pain in the child.

2 1. Heart failure causes ischemia leading to abdominal pain. Though heart failure can eventually lead to inadequate delivery of oxygen to tissue, this would not typically be the cause of abdominal pain in the child. A better explanation can be given to the mother to help her understand the child's pain. 2. Fluid overload causing congestion can lead to abdominal pain. Since many children with heart defects experience right-sided heart failure, they can experience congestion in the abdomen due to inadequate delivery of blood back to the heart. 3. H. pylori infections often occur in heart failure patients causing abdominal pain. H. pylori infections are not typically associated with heart failure, and therefore this would not be the correct explanation to give the mother. 4. Heart failure can lead to increased secretion of abdominal acids therefore causing stomach pain in the child. An increase in stomach acid secretion would not be expected in a patient expiring heart failure and therefore this would not be the explanation to provide to the mother.

What are some of the clinical manifestations associated with left-sided obstructive lesions? 1. Peripheral edema 2. Exercise intolerance 3. Right ventricle atresia 4. Pulmonary hypertension 5. Left ventricular hypertrophy

2,4,5 1. Peripheral edema Peripheral edema would not manifest from left-sided obstruction. 2. Exercise intolerance The left side of the heart supplies blood to systemic circulation. A left-side obstruction would decrease blood delivery and decrease exercise tolerance. 3. Right ventricle atresia Right ventricle atresia would have formed during development and would not be clinical manifestation of left-sided heart obstruction. 4. Pulmonary hypertension Increased pressure in left ventricle due to left-side heart obstruction can cause backflow into lungs and hypertension. 5. Left ventricular hypertrophy Increased pressure in left ventricle causes hypertrophy.

The nurse is assessing a pediatric patient with rhythm disturbance and decreased cardiac output (CO). What action should the nurse take? 1. Immediately begin CPR 2. Immediately notify the health care provider 3. Maintain observation until a collapse rhythm develops 4. Place child in Holter monitor, maintain 24-hour recordings

2 1. Immediately begin CPR CPR is not yet indicated, however if the child has bradycardia, assess the child's tolerance of the slow pulse. 2. Immediately notify the health care provider Pediatric rhythm disturbances should be treated as emergencies if they compromise cardiac output or have the potential to degenerate into lethal (collapse) rhythms (e.g., ventricular fibrillation). The health care provider should be immediately notified. 3. Maintain observation until a collapse rhythm develops Maintaining observation until a collapse rhythm (e.g. ventricular fibrillation) develops would not be indicated. Collapse rhythms can be lethal. 4. Place child in Holter monitor, maintain 24-hour recordings Child will likely already have ECG monitoring to observe disturbance and placing in a Holter monitor will not provide any additional information.

Which cardiac complication should cause changes in cardiac output (CO) after catheterization? 1. Phlebitis 2. Dysrhythmias 3. Peripheral thrombus 4. Vasospasm of catheterized vessel

2 1. Phlebitis Phlebitis is a complication that can occur secondary to vessel irritation and inflammation from insertion, but this is not a cardiac issue, therefore infection would not cause changes in CO. 2. Dysrhythmias Dysrhythmias can be hemodynamically compromising leading to decrease in cardiac output. 3. Peripheral thrombus A peripheral thrombus can impair blood flow distal to the thrombus. It would not have a direct effect on CO. 4. Vasospasm of catheterized vessel Vasospasm causes a local decrease in perfusion but would not alter CO.

Which statement best summarizes the differences between the fetal and neonatal heart in terms of oxygen saturation? 1. The oxygen saturation of the fetal heart constantly changes, whereas the oxygen saturation of the neonatal heart is consistent, albeit different, on each side. 2. The fetal heart has moderate oxygen saturation throughout, whereas the neonatal heart has low oxygen saturation on the right side & high oxygen saturation on the left side. 3. The fetal heart has very low oxygen saturation on the left side and very high oxygen saturation on the right, whereas the neonatal heart has low oxygen saturation on the right and high oxygen saturation on the left. 4. Both the fetal and neonatal hearts differ in oxygen saturation based on the side of the heart, with the fetal heart having moderate oxygen saturation on the right side and the neonatal heart having high oxygen saturation on the right side.

2 1. The oxygen saturation of the fetal heart constantly changes, whereas the oxygen saturation of the neonatal heart is consistent, albeit different, on each side. Fetal oxygen saturation is consistent on each side and does not constantly change. 2. The fetal heart has moderate oxygen saturation throughout, whereas the neonatal heart has low oxygen saturation on the right side & high oxygen saturation on the left side. Fetal blood is oxygenated by the placenta and receives moderate oxygen saturation. This blood is delivered to the heart. No change in oxygen saturation occurs in the fetal heart due to nonfunctional lungs. In the neonate, after the fetal shunts have closed, deoxygenated (low oxygen saturation) blood returns to the right side of the heart. The left side of the heart receives oxygenated (high oxygen saturation) blood from the lungs. 3. The fetal heart has very low oxygen saturation on the left side and very high oxygen saturation on the right, whereas the neonatal heart has low oxygen saturation on the right and high oxygen saturation on the left. Because the lungs are nonfunctional, the fetal blood is oxygenated by the placenta. This results in moderate oxygen saturation of the fetal heart and not very high or very low. 4. Both the fetal and neonatal hearts differ in oxygen saturation based on the side of the heart, with the fetal heart having moderate oxygen saturation on the right side and the neonatal heart having high oxygen saturation on the right side. The neonatal heart does not have high oxygen saturation on the right side of the heart. Once the fetal shunts close, deoxygenated, not oxygenated blood returns to the right side of the heart.

The nurse notes that QP/QS ratio (pulmonary-to-systemic ratio) is normal, however the right side of the heart has increased saturation. What conclusion can be drawn from this data? 1. There is a right-to-left shunt. 2. There is a left-to-right shunt. 3. There is increased blood flow out of the right ventricle. 4. There is decreased pulmonary blood flow leading to pulmonary hypotension.

2 1. There is a right-to-left shunt. When pulmonary-to-systemic ratio is norma, equal amounts of blood are being pumped by both sides of the heart. A right-to- left shunt would decrease oxygen saturation on the left side of the heart. 2. There is a left-to-right shunt. When pulmonary-to-systemic ratio is normal, equal amounts of blood are being pumped by both sides of the heart. The increase in oxygen saturation in the right side of the heart indicates blood must be shunting from left side to right. 3. There is increased blood flow out of the right ventricle. When pulmonary-to-systemic ratio is normal, equal amounts of blood are being pumped by both sides of the heart. 4. There is decreased pulmonary blood flow leading to pulmonary hypotension. When pulmonary-to-systemic ratio is normal, equal amounts of blood are being pumped by both sides of the heart. This would not lead to hypotension.

What is the most important rationale for monitoring nutritional intake in a child with heart failure (HF)? 1. To determine if child is expending enough energy. The more child eats, the more energy they can expend. 2. To determine if child is obtaining enough nutrients to support increased energy demands of the heart. 3. To determine if patient has pain associated with heart failure, as increased pain will result in decreased dietary intake. 4. To determine extent and sidedness of heart failure. Right-sided failure will not alter feeding habits. Left-sided failure results in decreased appetite and subsequent weight loss.

2 1. To determine if child is expending enough energy. The more child eats, the more energy they can expend. Energy use in a child with heart failure is high as myocardium is stressed to increase work. These children often expend more energy than they take in and subsequently lose weight. 2. To determine if child is obtaining enough nutrients to support increased energy demands of the heart. If less nutrition is consumed while more energy is expended, resulting in fewer calories being consumed, the child will develop failure to thrive (FTT). 3. To determine if patient has pain associated with heart failure, as increased pain will result in decreased dietary intake. Pain may be present with heart failure but nutritional intake is not a diagnostic measure of pain. 4. To determine extent and sidedness of heart failure. Right-sided failure will not alter feeding habits. Left-sided failure results in decreased appetite and subsequent weight loss. Nutritional intake cannot be used to determine extent or sidedness of heart failure.

A young child presents to the primary care clinic for a well-visit. During the cardiac assessment, the nurse hears a murmur during S2 and a heart rate of 90 bpm. The nurse notes that the child is below average height. Based on this information, what is the likely cause of the child's murmur? 1. Trauma 2. Structural defect 3. Tachydysrhythmia 4. Poor peripheral perfusion

2 1. Trauma Although trauma may cause a heart murmur, this child is in for a well-visit, suggesting that this patient has not suffered a recent trauma. 2. Structural defect Pathologic murmurs reflect an abnormality in the heart structure such as with congenital heart disease (CHD). Additionally, this defect may impair the child's normal growth. 3. Tachydysrhythmia Tachydysrhythmia describes an abnormal heartbeat with a rate > 100 beats per minute. Additionally, it is not a cause for a murmur. 4. Poor peripheral perfusion Poor peripheral perfusion is a clinical manifestation of tachydysrhythmias and not a cause for a murmur.

A child with aortic stenosis may experience symptoms of myocardial infarction (MI). How can these symptoms occur in a patient without vascular disease? 1. A child with aortic stenosis experiences MI symptoms due to the maximal exertion required by the left side of the heart. 2. Decreased pressure in the aorta results in decreased elastic recoil. Subsequently, less blood is delivered to the coronary arteries. 3. A child with aortic stenosis experiences MI symptoms due to the decrease in oxygenated blood returning to the heart from the lung. 4. Increased pressure in the aorta results in increased elastic recoil. Subsequently, more blood is delivered to systemic circulation than to coronary circulation.

2 Rationale in Sherpath: Severe HF; decreased CO and peripheral perfusion (critical aortic stenosis) If uncorrected, chest pain, dizziness, and syncope due to decreased flow into coronary arteries 1. A child with aortic stenosis experiences MI symptoms due to the maximal exertion required by the left side of the heart. The left ventricle does have an increased workload in aortic stenosis but this is not the cause of the MI symptoms. 2. Decreased pressure in the aorta results in decreased elastic recoil. Subsequently, less blood is delivered to the coronary arteries. Aortic stenosis results in high left ventricular pressures as the blood has difficulty leaving the ventricle through the stenosis. This prevents a normal increase in aortic stretch due to high volume and pressure. During ventricular diastole, less elastic recoil of the aorta results in less blood entering the coronary arteries, resulting in symptoms of MI. 3. A child with aortic stenosis experiences MI symptoms due to the decrease in oxygenated blood returning to the heart from the lung. Aortic stenosis does not cause a change in the oxygenation of the blood returning to the heart from the lungs. 4. Increased pressure in the aorta results in increased elastic recoil. Subsequently, more blood is delivered to systemic circulation than to coronary circulation. Aortic stenosis would decrease pressure in the aorta and decrease elastic recoil, therefore this would not be the cause of the MI symptoms.

Which statement explains the appearance of cyanosis in an individual with polycythemia secondary to congenital heart disease (CHD)? 1. Cyanosis will not be evident due to the significant increase in hemoglobin. 2. Cyanosis will appear in the presence of higher oxygen saturation levels (less desaturated) than normal. 3. Cyanosis will appear in the presence of lower oxygen saturation levels (increased desaturation) than normal. 4. Cyanosis is related to anemia, not polycythemia. Cyanosis is not expected in a patient with polycythemia secondary to CHD.

2 1. Cyanosis will not be evident due to the significant increase in hemoglobin. Polycythemia results from an increase in RBC concentration (therefore hemoglobin concentration). Even in polycythemia, cyanosis will be evident. 2. Cyanosis will appear in the presence of higher oxygen saturation levels (less desaturated) than normal. In children with polycythemia, cyanosis will appear when hemoglobin is less desaturated. 3. Cyanosis will appear in the presence of lower oxygen saturation levels (increased desaturation) than normal. In patients with polycythemia, cyanosis will not appear with lower oxygen saturation levels than normal. 4. Cyanosis is related to anemia, not polycythemia. Cyanosis is not expected in a patient with polycythemia secondary to CHD. Cyanosis can appear in patients with anemia and polycythemia.

A normal rhythm appears on the electrocardiogram (ECG) rhythm strip, but when the nurse palpates for a pulse it is not present. Which condition does this patient likely have? 1. Asystole 2. Pulseless electrical activity (PEA) 3. Supraventricular tachycardia (SVT) 4. Primary cardiac bradydysrhythmia

2 1. Asystole In asystole, electrical cardiac activity is absent. There is no electrical or myocardial activity. 2. Pulseless electrical activity (PEA) PEA indicates that the electrical events of cardiac conduction are occurring but cannot generate myocardial contraction and cardiac output. This results in a normal rhythm appearing on the ECG, but no palpable pulse. 3. Supraventricular tachycardia (SVT) SVT would have both electrical and myocardial activity to generate a fast pulse. 4. Primary cardiac bradydysrhythmia Primary cardiac bradydysrhythmia would have both electrical and myocardial activity to generate a slow pulse.

What is the greatest risk factor for development of infective endocarditis? 1. Tachypnea 2. Poor oral hygiene 3. Poor dietary intake 4. Low blood pressure

2 1. Tachypnea Increased breathing rate does not increase the risk of IE since breathing rates are not related to developing IE. 2. Poor oral hygiene The risk of IE is greater in individuals with poor oral hygiene. Poor oral hygiene leads to increased levels of mouth bacteria, including viridans streptococci, which are known to cause dental carries. 3. Poor dietary intake Patients with a poor dietary intake do not have an increased risk of IE since certain bacteria related to food rather than dietary intake is related to IE. 4. Low blood pressure Individuals with low BP do not have an increased risk of IE since low blood is not related to infective endocarditis.

What neurological manifestations expected in a patient with rheumatic fever should be reported to the provider by the nurse? (SATA) 1. Stroke due to hypoperfusion 2. Stroke due to Thrombotic emboli 3. Syncope due to Sydenham's Chorea 4. Seizures due to Sydenham's Chorea

2,3,4 1. Stroke due to hypoperfusion A cerebrovascular accident causing hypoperfusion would not likely be found in a patient with suffering from Rheumatic fever. 2. Stroke due to Thrombotic emboli A child with rheumatic fever may suffer from serious neurological problems but stroke due to a thrombotic embolic would more likely affect a child with IE. 3. Syncope due to Sydenham's Chorea Though syncope can occur in any child suffering from a disease, this is not the manifestation that would need to be reported to the provider. 4. Seizures due to Sydenham's Chorea A child suffering from Sydenham's Chorea may suffer from seizures and therefore this would need to be reported to the provider.

What neurological manifestations expected in a patient with rheumatic fever should be reported to the provider by the nurse? 1. Stroke due to hypoperfusion 2. Stroke due to Thrombotic emboli 3. Syncope due to Syndenham's Chorea 4. Seizures due to Syndenham's Chorea

2,3,4 1. Stroke due to hypoperfusion A cerebrovascular accident causing hypoperfusion would not likely be found in a patient with suffering from Rheumatic fever. 2. due to Thrombotic emboli A child with rheumatic fever may suffer from serious neurological problems but stroke due to a thrombotic embolic would more likely affect a child with IE. 3. Syncope due to Sydenham's Chorea Though syncope can occur in any child suffering from a disease, this is not the manifestation that would need to be reported to the provider. Correct 4. Seizures due to Sydenham's Chorea A child suffering from Sydenham's Chorea may suffer from seizures and therefore this would need to be reported to the provider.

Which cardiac catheterization complication directly causes occlusion of the blood vessel? 1. Infection 2. Hemorrhage 3. Embolus formation 4. Reaction to injected dye

3 1. Infection Infection would typically cause inflammation at the catheter insertion site but would not occlude the vessel. 2. Hemorrhage Hemorrhage is the leakage of blood from the vessel, the opposite of blood vessel occlusion. 3. Embolus formation Thrombus formation at catheter insertion site may impair perfusion to affected limb and may shed emboli that can travel anywhere in vascular system depending on cardiac anatomy, including the lung or brain 4. Reaction to injected dye A reaction to the injected dye may cause a rash, pruritus, vomiting, or anaphylaxis. It would not cause the occlusion of the blood vessel.

What is the benefit of maintaining a patent ductus arteriosus (PDA) for a child with tetralogy of Fallot? 1. PDA can be maintained to eliminate cyanosis. 2. PDA will help to maintain the pulmonary blood flow. 3. PDA can be maintained to decrease aortic blood flow. 4. PDA may decrease the shunting of blood from the left side.

3 1. PDA eliminates cyanosis. PDA does not eliminate cyanosis. Chronic hypoxemia results in tetralogy of Fallot. 2. PDA can be maintained to eliminate cyanosis. Though the PDA is open during fetal circulation, it normally closes after birth. Maintaining a PDA in a child with a cyanotic heart lesion can help to reduce the amount of cyanosis experienced by the child but will not eliminate the cyanosis. 3. PDA will help to maintain the pulmonary blood flow. Tetralogy of Fallot is associated with pulmonary stenosis and right ventricular outflow tract obstruction. This leads to a right-to-left shunt. Maintaining the PDA will create an alternative pathway for blood to take to the lungs and therefore help to oxygenate blood and reduce hypoxemia experienced by the child. 4. PDA can be maintained to decrease aortic blood flow. When a PDA is maintained in a child with tetralogy of Fallot, the patency can help to reduce rather than increase the amount of deoxygenated blood entering the aorta. This statement therefore does not explain the benefit of maintaining the PDA. 5. PDA may decrease the shunting of blood from the left side. The PDA normally closes at birth but in children with certain cyanotic heart lesions, the PDA can be maintained to help increase oxygenation of the blood. A PDA will not decrease but rather increase shunting of blood to the right side allowing for partial oxygenation.

Coarctation of the aorta increases afterload and cardiac workload. Which form of cardiomyopathy may develop related to the increased afterload and how would the nurse describe the progression to the family? 1. Atrophic; the myocardium begins to atrophy due to immediate failure. 2. Restrictive; the myocardium does not enlarge, but it becomes fibrotic to decrease dilation. 3. Hypertrophic; cardiac hypertrophy develops to match the afterload and maintain cardiac output. 4. Dilated; dilation of the myocardium develops to accommodate the increase in end diastolic volume.

3 1. Atrophic; the myocardium begins to atrophy due to immediate failure. Atrophic cardiomyopathy does not exist and therefore this would not be used in the explanation to the family. 2. Restrictive; the myocardium does not enlarge, but it becomes fibrotic to decrease dilation. Restrictive cardiomyopathy would not develop in this patient. Restrictive cardiomyopathy is caused by abnormal material infiltrating the myocardium. 3. Hypertrophic; cardiac hypertrophy develops to match the afterload and maintain cardiac output. Initially, hypertrophic cardiomyopathy develops as the heart attempts to overcome the afterload and maintain CO. In the long-term, the hypertrophic heart begins to fail and dilated cardiomyopathy develops. 4. Dilated; dilation of the myocardium develops to accommodate the increase in end diastolic volume. Dilated cardiomyopathy would occur in the late stages of the disease progression.

Closure of the ductus arteriosus occurs shortly after birth. Children born with right-to left shunts begin to experience an increase in cyanosis with this closure. Which explanation describes the pathophysiology of this clinical manifestation? 1. Closure of the patent ductus arteriosus (PDA) decreases the right-to-left shunting. 2. Closure of the ductus arteriosus will not cause the development of hypertension. 3. Closure of ductus arteriosus decreases the volume of blood going to the lungs for oxygenation. 4. Closure of the ductus arteriosus increases the volume of blood going to the lungs. Increased blood flow causes decreased oxygenation.

3 1. Closure of the patent ductus arteriosus (PDA) decreases the right-to-left shunting. Closure of the ductus arteriosus will not decrease the right-to-left shunt. 2. Closure of the ductus arteriosus causes the development of pulmonary hypertension. 3. Closure of the ductus arteriosus will not cause the development of hypertension. In fact, closure of this structure would decrease pulmonary pressures. Closure of ductus arteriosus decreases the volume of blood going to the lungs for oxygenation. In a right-to-left shunt, deoxygenated blood mixes with the oxygenated blood on the left side of the heart. This can decrease blood flow through the pulmonary trunk. When there is a PDA, mixed blood from the left side can go to the lungs for oxygenation. When the ductus arteriosus closes, this alternate pathway for oxygenation is lost. 4. Closure of the ductus arteriosus increases the volume of blood going to the lungs. Increased blood flow causes decreased oxygenation. Closure of the ductus arteriosus will not cause an increase in blood flow to pulmonary circulation.

What is the relationship between right-sided heart failure and pulmonary artery stenosis? 1. Decreased pressures on the right side of the heart cause backflow, peripheral edema and failure. 2. Increased blood flow to the pulmonary circulation can lead to right-sided heart failure due to increased workload. 3. Increased pressure developed in the right ventricle can cause hypertrophy and eventual failure of the right side of the heart. 4. Decreased venous return limits the preload on the right side of the heart. This leads to the development of pulmonary artery stenosis.

3 1. Decreased pressures on the right side of the heart cause backflow, peripheral edema and failure. Pulmonary artery stenosis does not cause decreased pressure on the right side of the heart. 2. Increased blood flow to the pulmonary circulation can lead to right-sided heart failure due to increased workload. Pulmonary stenosis would decrease blood flow to the lungs. 3. Increased pressure developed in the right ventricle can cause hypertrophy and eventual failure of the right side of the heart. Development of hypertrophy and the increased workload of the right ventricle are caused by the stenotic PA. The RV has to increase its contraction efforts to overcome the resistance from the PA, and this can lead to right sided heart failure. 4. Decreased venous return limits the preload on the right side of the heart. This leads to the development of pulmonary artery stenosis. Pulmonary stenosis is the lesion that causes the right-sided failure, not the reverse.

The nurse is caring for a child with incomplete closure of the aortic semilunar valve. How does the nurse describe the normal function of this valve to the patient's family? 1. Facilitates blood flow into the atria 2. Facilitates blood flow into the vena cava 3. Prevents blood from flowing back into the ventricle 4. Prevents blood from flowing into the pulmonary trunk

3 1. Facilitates blood flow into the atria The aortic semilunar valve is not positioned to regulate blood flow into the atria. 2. Facilitates blood flow into the vena cava The aortic semilunar valve is not positioned to regulate blood flow into the vena cava. 3. Prevents blood from flowing back into the ventricle The aortic semilunar valve regulates blood flow from the ventricles to the aorta. If this valve does not close, blood will flow back into the ventricles. 4. Prevents blood from flowing into the pulmonary trunk The aortic semilunar valve regulates blood flow into the aorta, not the pulmonary trunk. The pulmonary semilunar valve regulates blood flow to the pulmonary trunk.

Auscultation is an important aspect of the cardiac assessment. Which sentence helps to explain why both the bell and diaphragm of the stethoscope are used during the assessment? 1. The bell is used to identify dysrhythmias; the diaphragm identifies murmurs 2. The bell is used to identify normal heart sounds; the diaphragm is used to identify murmurs 3. The bell is used to identify low-pitched sounds; the diaphragm is used to identify high-pitched sounds 4. The bell is used to identify high-pitched, normal heart sounds; the diaphragm identifies low-pitched murmurs

3 1. The bell is used to identify dysrhythmias; the diaphragm identifies murmurs. The bell and diaphragm are not used independently to identify dysrhythmias and murmurs. 2. The bell is used to identify normal heart sounds; the diaphragm is used to identify murmurs. The bell and diaphragm can both be used to hear normal heart sounds and murmurs. 3. The bell is used to identify low-pitched sounds; the diaphragm is used to identify high-pitched sounds. Both low- and high-pitched sounds are heard during auscultation of the heart. S1 is lower pitch, S2 is higher pitch. To clearly hear both heart sounds, both the bell and diaphragm should be used. 4. The bell is used to identify high-pitched, normal heart sounds; the diaphragm identifies low-pitched murmurs. Not all high-pitched sounds are normal and not all low-pitched sounds are murmurs. Therefore, the bell and diaphragm are not used in this way. Additionally, the bell and diaphragm are not optimized to identify high- and low-pitched sounds, respectively.

A student athlete with a normal physical exam collapses during practice. The athlete's brother states that their uncle passed away at 19-years-old while playing soccer. What assumption regarding cardiac pathology could be made based on this data? 1. The patient has infective endocarditis. 2. The patient has rheumatic heart disease. 3. The patient has hypertrophic cardiomyopathy. 4. The patient has coronary artery aneurysm related to Kawasaki disease.

3 1. The patient has infective endocarditis. Infective endocarditis does not have a genetic component and the physical exam may have revealed a murmur and therefore this assumption cannot be made based on the information given. 2. The patient has rheumatic heart disease. Rheumatic heart disease does not have a genetic component. Physical exam would have revealed a murmur. 3. The patient has hypertrophic cardiomyopathy. Hypertrophic cardiomyopathy has a genetic predisposition. Approximately 50% of cases of sudden death in athletes are related to HCM. 4. The patient has coronary artery aneurysm related to Kawasaki disease. Even if a patient has a history of coronary artery aneurysm, there are key findings in the patient's history that indicate other causes.

Which treatment is given priority for the prevention of subsequent cardiac valve damage in rheumatic fever? 1. Use of low-dose aspirin for anti-platelet aggregation 2. Use of high-dose aspirin for anti-inflammatory properties 3. Use of antibiotic prophylaxis to prevent bacterial infection 4. Use of corticosteroids to prevent reduce inflammation and immune response

3 1. Use of low-dose aspirin for anti-platelet aggregation Low-dose aspirin will not prevent subsequent cardiac valve damage in RF. 2. Use of high-dose aspirin for anti-inflammatory properties High-dose aspirin has anti-inflammatory properties but will not prevent subsequent cardiac valve damage in RF. 3. Use of antibiotic prophylaxis to prevent bacterial infection Antibiotic prophylaxis is used to prevent subsequent infection by streptococcal bacteria, which would cause further valve damage. 4. Use of corticosteroids to prevent reduce inflammation and immune response Corticosteroids will reduce inflammation and immune response but this is not the underlying cause of the cardiac valve damage in RF.

Tachycardia, though initially beneficial, potentiates heart failure in the long-term. What is the relationship between tachycardia and heart failure? 1. Tachycardia will increase heart's consumption of oxygen that will decrease delivery of oxygen in systemic circulation. 2. Tachycardia alters the oxygenation that occurs in lungs, leading to decreased oxygen saturation. This change leads to heart failure. 3. Increased heart rate (HR) increases metabolic demand and decreases filling and resting time for the heart. These changes lead to heart failure. 4. Increased HR will increase coronary artery perfusion and increase oxidative stress in the heart muscle. These changes lead to heart failure.

3 Rationale in Sherpath: Neurohormonal stimulation of the sympathetic nervous system helps to maintain blood pressure, blood flow, and oxygen delivery to vital organs. With decreased CO, there is stimulation of the sympathetic nervous system. Initially this leads to increased HR, contractility, and SV; increased systemic vascular resistance (afterload); and selective peripheral vasoconstriction. Tachycardia, although beneficial to compensate for early HF, increases myocardial oxygen consumption, decreases the diastolic filling time and resting phase of the heart, and decreases coronary artery perfusion. 1. Tachycardia will increase heart's consumption of oxygen that will decrease delivery of oxygen in systemic circulation. Tachycardia will increase oxygen consumption by the myocardium. This will not alter oxygen saturation of the blood in systemic circulation. 2. Tachycardia alters the oxygenation that occurs in lungs, leading to decreased oxygen saturation. This change leads to heart failure. Tachycardia will increase movement of blood into the lungs but should not cause changes in oxygen saturation. 3. Increased heart rate (HR) increases metabolic demand and decreases filling and resting time for the heart. These changes lead to heart failure. Tachycardia, although beneficial to compensate for early HF, increases myocardial oxygen consumption, decreases diastolic filling time and resting phase of the heart, and decreases coronary artery perfusion. Over time, this will lead to heart failure. 4. Increased HR will increase coronary artery perfusion and increase oxidative stress in the heart muscle. These changes lead to heart failure. Increased HR will not lead to an increase in coronary artery perfusion.

What change in the neonate is directly responsible for the closure of foramen ovale? 1. Increased blood flow to liver 2. Increased pulmonary blood flow 3. Increased pressure in left ventricle 4. Increased pulmonary oxygen saturation

3 1. Increased blood flow to liver When the umbilical cord is clamped, the ductus venosus closes and no longer diverts blood from the liver, however this does not directly result in closing of the foramen ovale. 2. Increased pulmonary blood flow Although an increase in pulmonary blood flow results in changes in oxygen saturation and closure of the ductus arteriosus, this is not the direct cause for closure of the foramen ovale. 3. Increased pressure in left ventricle When the umbilical cord is clamped and the placental blood flow is stopped, pressure in the left ventricle rises and exceeds pressure in the right ventricle. This difference in pressure is responsible for closing the foramen ovale. 4. Increased pulmonary oxygen saturation Increased pulmonary oxygen saturation is primarily responsible for the closure of the ductus arteriosus, not the foramen ovale.

A 12-year-old patient with a history of heart surgery comes to the emergency department complaining of dizziness and chest discomfort. What electrocardiogram (ECG) finding lets the nurse know a patient is in supra-ventricular tachycardia (SVT)? 1. Long Q-T interval 2. Wide QRS interval 3. Narrow QRS interval 4. Lack of cardiac rhythm

3 1. Long Q-T interval Long Q-T intervals indicate long Q-T syndrome. This is a chaotic tachycardia and not indicative of SVT. 2. Wide QRS interval Wide QRS on ECG with tachycardia indicates the impulse originates in the ventricle, suggesting ventricular tachycardia (VT) and not SVT. 3. Narrow QRS interval The presence of a narrow QRS on ECG with tachycardia indicates the impulse begins above (superior to) the ventricles and suggests SVT. 4. Lack of cardiac rhythm A lack of cardiac rhythm is a medical emergency and indicates lack of cardiac output. It suggests the patient is in asystole, not SVT.

Pulmonary artery stenosis can precipitate regurgitation and prevent the closure of the foramen ovale. Which manifestation can occur if the foramen ovale remains patent in a patient with pulmonary stenosis? 1. Decreased blood flow to the systemic circulation 2. Increased blood flow to the pulmonary circulation 3. Decreased oxygenation of blood entering systemic circulation 4. Increased oxygenation of blood entering systemic circulation

3 Rationale in Sherpath: Severe pulmonary artery obstruction elevates RV pressure causing blood to regurgitate into the RA; rising RA pressure forces the foramen ovale open, allowing blood to flow from the right to the left side of the heart 1. Decreased blood flow to the systemic circulation The patent foramen ovale does not decrease blood flow to the systemic circulation. Instead, it will increase blood flow to the systemic circulation. 2. Increased blood flow to the pulmonary circulation The patent foramen ovale does not increase blood flow to the pulmonary circulation. Instead, it will decrease blood flow to the pulmonary circulation. 3. Decreased oxygenation of blood entering systemic circulation The patent foramen ovale allows the blood to bypass the pulmonary circulation. Blood contains lower oxygen saturation levels when entering systemic circulation. 4. Increased oxygenation of blood entering systemic circulation The patent foramen ovale does not lead to an increase in oxygen saturation levels of blood entering systemic circulation. The patent foramen ovale allows blood from the right side of the heart (deoxygenated) to mix with the blood from the left side of the heart (oxygenated).

Which structures allow the fetal heart to compensate for nonfunctioning lungs? 1. Liver 2. Left ventricle 3. Foramen ovale 4. Ductus arteriosus 5. Superior vena cava

3,4 1. Liver The liver is partially bypassed in the fetus to increase the oxygen delivery to the heart. Although this bypass compensates for nonfunctioning lungs, the liver itself does not contribute to the compensation. 2. Left ventricle Although blood flow through the left ventricle is regulated by fetal valves that close after birth, and pressures in the ventricles are different between the fetus and neonate, the left ventricle does not directly compensate for nonfunctioning lungs in the fetus. 3. Foramen ovale The foramen ovale is a vessel that allows blood to bypass the lungs, allowing for more efficient blood flow in the absence of functioning lungs. 4. Ductus arteriosus The ductus arteriosus carries oxygenated blood from the placenta to the heart, allowing for oxygen delivery in the absence of functioning lungs. 5. Superior vena cava The superior vena cava delivers blood to the right atrium in both fetal and neonatal hearts. This structure does not compensate for nonfunctioning lungs.

What is the rationale for administering potent vasoconstriction agents to a child experiencing a hypercyanotic episode? 1. To decrease the afterload 2. To increase stroke volume 3. To increase systemic vascular resistance 4. To decrease the degree of right-to-left shunting 5. To increase blood flow into the pulmonary circulation

3,4,5 1. To decrease the afterload Vasoconstriction will not decrease afterload. The increase in peripheral resistance will increase afterload. 2. To increase stroke volume Vasoconstriction will not increase stroke volume. The change in afterload associated with vasoconstrictors will decrease stroke volume. 3. To increase systemic vascular resistance Vasoconstriction will increase systemic vascular resistance and help maintain BP. This increase in pressure will help limit shunting of blood, thereby helping to improve movement of blood out of right ventricle into pulmonary artery and to lungs for oxygenation. 4. To decrease the degree of right-to-left shunting Vasoconstriction can help to limit amount of blood that enters left ventricle through ventricular septal defects. This will help to limit amount of deoxygenated blood entering left ventricle and the aorta into systemic circulation. 5. To increase blood flow into the pulmonary circulation Potent vasoconstrictors can help to limit amount of deoxygenated blood that enters aorta and help to increase amount of blood entering pulmonary artery and lungs for proper oxygenation.

Which statements correctly describe the structures in the lower respiratory tract? Select all that apply. 1.The parietal pleura encases each lung. 2.The left main bronchus branches off the trachea. 3.The upper, middle, and lower lobes comprise the right lung. 4.The trachea conducts air between the pharynx and the lungs. 5.The alveoli are found at the terminal end of the main bronchi.

3,5 1.The parietal pleura encases each lung. The visceral pleura, not parietal pleura, encase each lung. The parietal pleura lines the entire thoracic cavity. 2.The left main bronchus branches off the trachea. The right main bronchus, not the left bronchus, branches off the trachea and it is shorter and wider than the left bronchus. 3.The upper, middle, and lower lobes comprise the right lung. The right lung has three lobes namely: upper, middle, and lower lobes. 4.The trachea conducts air between the pharynx and the lungs. The trachea conducts air between the larynx, not pharynx, and the lungs. 5.The alveoli are found at the terminal end of the main bronchi. The main bronchi, which are divided into lobar bronchi, segmental bronchi, and bronchioles, terminate in alveoli

A 12-month-old child with a respiratory infection begins crying while the nurse is auscultating for posterior lung sounds. Which intervention is most appropriate? 1.Stop the assessment to avoid stressing the child 2.Compress the stethoscope against the chest wall 3.Allow parent to hold child and continue with assessment 4.Encourage child to blow bubbles and continue assessment

3. 1.Stop the assessment to avoid stressing the child Stopping the assessment may relieve stress for the child who begins crying, but the nurse must still assess the child. 2.Compress the stethoscope against the chest wall Compressing the stethoscope against the chest wall can make it easier to hear end-expiratory sounds, but it is not the most appropriate intervention for this situation. 3.Allow parent to hold child and continue with assessment Allowing the parent to hold a child who begins crying while the nurse is auscultating the lungs may console the child from crying and it is the most appropriate intervention for this situation. 4.Encourage child to blow bubbles and continue assessment Encouraging the child to blow bubbles may promote breathing out more than usual and it is not an appropriate intervention for this situation.

In the electrical conduction system of the heart, where does the initial impulse start? 1. AV node 2. Bundle of His 3. Purkinje fibers 4. Sinus (SA) node

4 1. AV node The AV node does not set the normal rhythm of the heart but can take over if other signals do not function properly. 2. Bundle of His The Bundle of His does not set the normal rhythm of the heart. The Bundle of His has a slow intrinsic rhythm that is masked by the conduction from the primary electrical signal. 3. Purkinje fibers The Purkinje fibers are the last part of the conduction system and are not responsible for setting the normal heart rhythm. 4. Sinus (SA) node The sinus node (SA node), a group of spontaneously depolarizing cells, sets the normal "sinus" rhythm.

The mother of a child with tetralogy of Fallot states that over the past two weeks the child has been experiencing periodic episodes of increased cyanosis, irritability, and moments of deep breathing in the morning. After child is assessed and vitals appear stable what is the most important action for the nurse to take next? 1. Administer oxygen as needed. 2. Administer vasoconstrictors as ordered. 3. Reinforce the importance of the knee-chest position that can increase blood flow to the lungs. 4. Left-to-right shunting will cause volume overload on the heart. Contact the providers as the child is in need of a surgery consult.

4 1. Administer oxygen as needed. Administering oxygen will be important for any child with a right-to-left shunt who is at increased risk for hypoxemia. Though this will need to be done, it is not the most urgent action for the nurse to take. 2. Administer vasoconstrictors as ordered. Though administering vasoconstrictors will be a part of the care plan for the child since vasoconstrictors can increase arterial resistance and help reduce the blood flow through the right to left shunt, this will not be the priority action to take at the moment. 3. Reinforce the importance of the knee-chest position that can increase blood flow to the lungs. Getting the child into the knee-chest position will help to increase intrathoracic pressure, thereby helping to increase blood flow to the lung. Though this will be encouraged, it is not the most important action for the nurse to take. 4.Left-to-right shunting will cause volume overload on the heart. Contact the providers as the child is in need of a surgery consult. Left-to-right shunting will increase the volume on the right side of the heart, resulting in both volume and pressure overload. This child is experiencing "tet spells" that include episodes of increased cyanosis with crying, deep respirations, and other abnormal breathing patterns, and increased pulmonary venous return. This evidence of increased hypoxia leaves the child at risk for cerebrovascular accident. Surgical consult is necessary.

What is indicated when the point of maximal impulse (PMI) is found in a lower location than expected during the cardiac assessment? 1. Cardiac atrophy 2. Pericardial effusion 3. Increased cardiac contractility 4. Cardiac hypertrophy (enlargment)

4 1. Cardiac atrophy If cardiac atrophy were present, PMI would be at higher, not lower, location than expected. 2. Pericardial effusion With pericardial effusion there can be loss of visible PMI, but no shift in location is expected. 3. Increased cardiac contractility PMI position would be at normal position if there were an increase in cardiac contractility. Changes in contractility do not change position of heart in chest cavity. 4. Cardiac hypertrophy (enlargement) If PMI is located lower than expected, this can indicate cardiac hypertrophy (cardiac enlargement) as heart takes up more space.

Which statement helps to explain why a patient with Down syndrome might have a marked increase in pulmonary blood flow? 1. Patients with Down syndrome often have left-sided heart failure leading to pulmonary hypertension. 2. Patients with Down syndrome often have decreased pulmonary resistance that leads to increased pulmonary blood flow. 3. Patients with Down syndrome often have cardiac defects associated right-sided hypertrophy. The patient may have pulmonary stenosis. 4. Patients with Down syndrome often have cardiac defects associated with the genetic syndrome. The patient may have an atrioventricular septal defect (AVSD).

4 1. Patients with Down syndrome often have left-sided heart failure leading to pulmonary hypertension. Left-sided heart failure does lead to pulmonary hypertension; however, the hypertension occurs due to the back-up of blood from the left side of the heart into the pulmonary circulation. This would decrease pulmonary blood flow and is not the cause of the change seen in this patient. 2. Patients with Down syndrome often have decreased pulmonary resistance that leads to increased pulmonary blood flow. Decreased pulmonary resistance is not a manifestation of Down syndrome; therefore, this is not the cause of increased pulmonary blood flow. 3. Patients with Down syndrome often have cardiac defects associated right-sided hypertrophy. The patient may have pulmonary stenosis. Pulmonary stenosis will cause the development of right-sided hypertrophy; however, the stenosis would result in decreased pulmonary blood flow. 4. Patients with Down syndrome often have cardiac defects associated with the genetic syndrome. The patient may have an atrioventricular septal defect (AVSD). AVSD (atrioventricular septal defect) is often associated with genetic syndromes such as Down syndrome. In AVSD there is abnormal development of both septa and AV valves. Left-to-right shunting increases pulmonary blood flow.

Which statement describes the relationship between the ductus arteriosus and blood flow in the fetus? 1. Because pulmonary circulation pressure is high, the ductus arteriosus facilitates blood flow into the lungs. 2. The blood returning to the heart from the vena cava is directed through the ductus arteriosus to the left atrium. 3. The left atrium and left ventricle are nonfunctional in the infant. The ductus arteriosus diverts blood away from the left side of the heart. 4. Pulmonary circulation pressure is high; the ductus arteriosus directs blood away from the lungs and into the aorta.

4 1. Because pulmonary circulation pressure is high, the ductus arteriosus facilitates blood flow into the lungs. Although pulmonary circulation pressure is high in the fetus, the ductus arteriosus does not direct blood to the lungs. 2. The blood returning to the heart from the vena cava is directed through the ductus arteriosus to the left atrium. The blood returning to the heart from the vena cava can be directed through the foramen ovale, not ductus arteriosus, and into the left atrium. 3. The left atrium and left ventricle are nonfunctional in the infant. The ductus arteriosus diverts blood away from the left side of the heart. Both the left atrium and left ventricle are functional in the infant. The ductus arteriosus does not make a connection with those chambers. 4. Pulmonary circulation pressure is high; the ductus arteriosus directs blood away from the lungs and into the aorta. Pulmonary circulation pressure is high in the fetus. The ductus arteriosus provides a pathway from the pulmonary trunk to the descending aorta, bypassing the lungs. As the blood has already been oxygenated in the placenta, passage through the lungs is unnecessary.

What is the relationship between left-to-right shunt congenital heart defects and increased pulmonary blood flow? 1. Cardiac workload is increased but pulmonary blood flow is decreased. 2. Cardiac workload is decreased and this will decrease pulmonary blood flow. 3. Volume overload results in the left side of the heart. This decreases pulmonary blood flow. 4. Volume overload results in the right side of the heart and this increases pulmonary blood flow.

4 1. Cardiac workload is increased but pulmonary blood flow is decreased. Cardiac workload increases to manage additional volume but does not decrease pulmonary blood flow. 2. Cardiac workload is decreased and this will decrease pulmonary blood flow. Cardiac workload increases to manage additional volume but this will not decrease pulmonary blood flow. 3. Volume overload results in the left side of the heart. This decreases pulmonary blood flow. Volume shunts from the left to the right side of the heart so the left side will not have volume overload. 4. Volume overload results in the right side of the heart and this increases pulmonary blood flow. Volume shunts from the left to the right side of the heart resulting in right-sided volume overload. The increase in volume leads to an increase in pulmonary blood flow.

How should the nurse explain the reversal of a cardiac shunt due to pulmonary hypertension that went untreated? 1. Changes in the aorta lead to significantly increased aortic pressures. The pressure changes changed the direction of the shunt and now less blood is pumped to the lungs. 2. Changes in superior vena cava (SVC) cause pressure changes in the right atrium. The pressure changes changed the direction of the shunt and now less blood is pumped to the lungs. 3. Changes in the inferior vena cava (IVC) cause pressure changes in the right atrium. The pressure changes changed the direction of the shunt and now less blood is pumped to the lungs. 4. Changes in the pulmonary blood vessels led to significantly increased pulmonary pressures. The pressure differences changed the direction of the shunt and now less blood is pumped to the lungs for adequate oxygenation therefore causing cyanotic spells in the child.

4 1. Changes in the aorta lead to significantly increased aortic pressures. The pressure changes changed the direction of the shunt and now less blood is pumped to the lungs. This explanation would not help to explain the reversal in shunting. The pressure changes in the aorta would not likely be seen in this patient's situation. 2. Changes in superior vena cava (SVC) cause pressure changes in the right atrium. The pressure changes changed the direction of the shunt and now less blood is pumped to the lungs. Explaining changes in the superior vena cava would not help to explain the reversal in shunting. There are other vessels involved in pulmonary hypertension than the superior vena cava. 3. Changes in the inferior vena cava (IVC) cause pressure changes in the right atrium. The pressure changes changed the direction of the shunt and now less blood is pumped to the lungs. Explaining changes in the inferior vena cava would not help to explain the reversal in shunting. There are other vessels involved in pulmonary hypertension than the inferior vena cava. 4. Changes in the pulmonary blood vessels led to significantly increased pulmonary pressures. The pressure differences changed the direction of the shunt and now less blood is pumped to the lungs for adequate oxygenation therefore causing cyanotic spells in the child. Left-to-right shunts cause increased pressure in the pulmonary vein thereby leading to pulmonary hypertension in the child. This creates a thickened right ventricle therefore impeding blood flow in the left-to-right direction. The flow therefore reverses through the shunt bypassing adequate oxygenation.

What is the relationship between the fetal cardiac anatomical features and the survivability of complex cardiac lesions in the early neonatal stage? 1. Fetal structures can prevent the formation of pressure gradients and reduce shunting. 2. Patent fetal structures can be removed during surgery and used during the surgical repair. 3. Fetal structures close quickly to prevent aberrant flow. This prevents the mixing of oxygenated and deoxygenated blood. 4. Patent fetal structures maintain pathways for the movement of blood and allow for mixing of oxygenated and deoxygenated blood.

4 1. Fetal structures can prevent the formation of pressure gradients and reduce shunting. Fetal structures are designed for shunting blood away from the normal blood flow pathways not for preventing the formation of pressure gradients. This statement therefore does not reflect the relationship between anatomical features and the survivability of children with complex lesions. 2. Patent fetal structures can be removed during surgery and used during the surgical repair. Fetal structures are not removed and subsequently used for surgical repair of complex lesions. This statement does not reflect the relationship between anatomical features and the survivability of children with complex lesions. 3. Fetal structures close quickly to prevent aberrant flow. This prevents the mixing of oxygenated and deoxygenated blood. Closure of the fetal structures would decrease available pathways for the flow of blood. In children with complex lesions, it is important to maintain structures that increase the flow of blood that might otherwise be impeded by defects. 4. Patent fetal structures maintain pathways for the movement of blood and allow for mixing of oxygenated and deoxygenated blood. Fetal structures (foramen ovale and ductus arteriosus) that can be maintained after birth can improve survivability of patients with heart defects. Theses maintained pathways allow for the movement of blood around possible obstructions or due to pressure gradients. They also allow for the mixing of oxygenated and deoxygenated blood which can reduce hypoxia and therefore improve survivability in children with heart defects.

Which diagnostic test can be used for real-time visualization of both heart structures and function? 1. Holter monitor 2. Electrocardiogram (ECG) 3. Ventilation-perfusion scan 4. Echocardiography (ECHO)

4 1. Holter monitor Holter monitor records heart function but does not allow for visualization of heart structures. 2. Electrocardiogram (ECG) ECG provides real-time information regarding heart function but heart structures cannot be visualized. 3. Ventilation-perfusion scan Ventilation-perfusion scan provides information about blood flow and gas flow in the lungs and does not provide information about heart structure. Correct 4. Echocardiography (ECHO) ECHO generates an image of the heart and heart structures. In real-time, structures and functions can be evaluated.

How can a nurse distinguish between a patient with hypoplastic left heart syndrome and truncus arteriosus? 1. Oxygenated blood flows to left ventricle in hypoplastic left heart syndrome, whereas deoxygenated blood flows into left heart in truncus arteriosus. 2. Oxygenated blood flows to right atrium in hypoplastic left heart syndrome, whereas deoxygenated blood flows into left heart in truncus arteriosus. 3. Deoxygenated blood flows to the left atrium in hypoplastic left heart syndrome, whereas deoxygenated blood flows into the left heart in truncus arteriosus. 4. Oxygenated blood flows to left atrium in hypoplastic left heart syndrome, whereas oxygenated blood flows into left ventricle where blood mixing occurs in truncus arteriosus.

4 1. Oxygenated blood flows to left ventricle in hypoplastic left heart syndrome, whereas deoxygenated blood flows into left heart in truncus arteriosus. Saturated blood flows to left atrium in hypoplastic left heart syndrome, whereas desaturated blood flows into left ventricle in truncus arteriosus. 2. Oxygenated blood flows to right atrium in hypoplastic left heart syndrome, whereas deoxygenated blood flows into left heart in truncus arteriosus. Saturated blood flows to left atrium in hypoplastic left heart syndrome, but is unable to reach left ventricle because of hypoplasia. This forces blood to right side of the heart, usually through an atrial septal defect. 3. Deoxygenated blood flows to the left atrium in hypoplastic left heart syndrome, whereas deoxygenated blood flows into the left heart in truncus arteriosus. Saturated blood flows to left atrium in hypoplastic left heart syndrome, whereas more blood mixing occurs in left heart in truncus arteriosus. 4. Oxygenated blood flows to left atrium in hypoplastic left heart syndrome, whereas oxygenated blood flows into left ventricle where blood mixing occurs in truncus arteriosus. These findings will help a nurse distinguish patient with hypoplastic left heart syndrome from one with truncus arteriosus. In hypoplastic heart syndrome, most of oxygenated blood cannot leave aorta and is instead shunted to right side back in to pulmonary circulation.

A nurse is measuring blood pressure (BP) in a patient with a stenotic lesion. What should the nurse expect when comparing blood pressures proximal and distal to the lesion? 1. Proximal and distal pressures will be the same; it is the rate of flow that is different. 2. Proximal and distal pressures will be the same since the blood flow rate will be the same. 3. Proximal to the lesion, pressure will be low or absent; distal to the lesion, pressure will be increased. 4. Proximal to the lesion, pressure will be high; distal to the lesion, pressure will be decreased or absent.

4 1. Proximal and distal pressures will be the same; it is the rate of flow that is different. There will be varying pressures at both the proximal and distal areas from the lesion, and therefore the nurse would not expect to see the same pressures in these areas. 2. Proximal and distal pressures will be the same since the blood flow rate will be the same. The blood pressure at the proximal and distal area of the lesion will be different as well as the flow rates at each of these locations. The nurse would therefore not expect to see the same flow rates and same pressures. 3. Proximal to the lesion, pressure will be low or absent; distal to the lesion, pressure will be increased. Blood pressure exerts a force against the obstruction. There are no equivalent forces on the distal side of the obstruction or stenosis. 4. Proximal to the lesion, pressure will be high; distal to the lesion, pressure will be decreased or absent. Pressure increases proximal to the lesion (obstruction/stenosis). Distal to the lesion, pressures are decreased. The force of BP pushes against the obstruction. After the obstruction, no additional force is generated.

A patient with Kawasaki disease shows signs of cardiac involvement. Why does the nurse need to emphasize the importance of maintaining cardiology check-ups throughout life? 1. Pulmonary hypertension may develop as venous congestion results from left-side heart failure. 2. Development of collateral vessels in the heart around a stenotic lesion may increase workload on the heart. 3. Activation of the immune response to bacterial infection can cause damage to the vessels and increase risk of myocardial infarction. 4. Aneurysms formed during the subacute phase of the disease can rupture later in life or cause stenosis and eventual myocardial infarction.

4 1. Pulmonary hypertension may develop as venous congestion results from left-side heart failure. Left side heart failure can cause venous congestion and pulmonary hypertension. However, left-side heart failure in Kawasaki disease is uncommon without other preceding complications. 2. Development of collateral vessels in the heart around a stenotic lesion may increase workload on the heart. The development of collateral vessels would be beneficial to maintaining blood supply to the myocardium. A change in workload would be miniscule. 3. Activation of the immune response to bacterial infection can cause damage to the vessels and increase risk of myocardial infarction. During the normal immune response, vessel damage would not occur and would not be a cause of continued cardiology check-ups throughout life. 4. Aneurysms formed during the subacute phase of the disease can rupture later in life or cause stenosis and eventual myocardial infarction. Monitoring the coronary arteries is essential when cardiac involvement is noted in Kawasaki disease. Aneurysms can rupture and stenotic lesions can cause occlusions resulting in myocardial infarction.

A child joins the soccer team and experiences dyspnea and some chest pain but assumes he is out of shape. That night he sleeps sitting up in the recliner because he can breathe better. After three days of this routine, his mother takes him to the clinic and he is diagnosed with hypertrophic cardiomyopathy. What pathophysiological event will the nurse need to manage in this patient? 1. Tachycardia. 2. Systolic murmur. 3. Peripheral edema. 4. Pulmonary venous congestion.

4 1. Tachycardia. Tachycardia would increase the work of the heart and could cause angina but would not cause dyspnea. 2. Systolic murmur. The systolic murmur may be the cause of the hypertrophic cardiomyopathy but not the dyspnea. 3. Peripheral edema. Peripheral edema would not affect the lungs or gas exchange to cause dyspnea. 4. Pulmonary venous congestion. Pulmonary venous congestion can decrease the rate of gas exchange and cause dyspnea.

In patients with coarctation of the aorta, infusion of prostaglandin E1 may be used to keep the ductus arteriosus open. What is the rationale for facilitating patent ductus arteriosus (PDA) when the patient has coarctation of the aorta? 1. To increase oxygenation of blood entering descending aorta 2. To increase pressures in left ventricle and force perfusion of aorta 3. To decrease blood flow distal to lesion and increase blood flow to pulmonary circulation. PDA maintains flow from aorta to lungs 4. To increase blood flow to descending aorta by allowing deoxygenated blood from pulmonary trunk to mix with blood distal to lesion

4 1. To increase oxygenation of blood entering descending aorta Blood entering from PDA will be deoxygenated. 2. To increase pressures in left ventricle and force perfusion of aorta PDA would not increase pressures in left ventricles. 3. To decrease blood flow distal to lesion and increase blood flow to pulmonary circulation. PDA maintains flow from aorta to lungs PDA is not needed to facilitate blood flow to lungs. 4. To increase blood flow to descending aorta by allowing deoxygenated blood from pulmonary trunk to mix with blood distal to lesion Coarctation of the aorta is an obstructive lesion that decreases blood supply to abdominal organs and lower periphery. Maintaining PDA will increase blood flow in the descending aorta.

How should the nurse describe dilated cardiomyopathy to an adolescent patient? 1. When the heart chambers have increased in strength of the muscle but decreased in volume, this describes hypertrophic cardiomyopathy. 2. When the heart chambers have not changed in size but have decreased in volume, this describes restrictive cardiomyopathy. 3. When the heart chambers have increased in strength of the muscle and there was no change in volume, this describes a functional hypertrophy that may occur in athletes. 4. Dilated cardiomyopathy means the heart chambers have increased volume but not in strength of the muscle. More volume fills the ventricular chambers but the muscle is not strong enough to properly eject the volume.

4 1. When the heart chambers have increased in strength of the muscle but decreased in volume, this describes hypertrophic cardiomyopathy. Cardiomyopathy can be classified by size and function of the heart's pumping chambers. Hypertrophic cardiomyopathy occurs when the ventricular muscle thickness increases in size thereby causing a decrease in volume. 2. When the heart chambers have not changed in size but have decreased in volume, this describes restrictive cardiomyopathy. Cardiomyopathy is classified by size and function of the heart's pumping chambers. Dilated cardiomyopathy means the heart chambers have changed in size rather than having no change in size. 3. When the heart chambers have increased in strength of the muscle and there was no change in volume, this describes a functional hypertrophy that may occur in athletes. Cardiomyopathy is classified by size and function of the heart's pumping chambers. When a patient presents with dilated cardiomyopathy they will have a decrease rather than increase in strength of muscle. 4. Dilated cardiomyopathy means the heart chambers have increased volume but not in strength of the muscle. More volume fills the ventricular chambers but the muscle is not strong enough to properly eject the volume. Cardiomyopathy is classified by size and function of the heart's pumping chambers. Dilated cardiomyopathy means the heart chambers have increased volume but not in strength of the muscle.

A patient with asymptomatic hypertrophic cardiomyopathy is prescribed beta-blocker prophylaxis. The parents would like to know why their child is receiving a medication when no symptoms are evident. What explanation describes the function of the beta-blocker prophylaxis? 1. Beta blockers are used to prevent problems with the valves of the heart. 2. Beta blockers are used to increase the heart rate to induce good blood output. 3. Beta blockers are used as a preventative measure to increase the pump and blood output of the heart. 4. Beta blockers are used to prevent the development of abnormal heart rhythms that can be life threatening.

4 Beta blockade is also used as prophylaxis against ventricular dysrhythmias. Prophylactic therapy may be started in asymptomatic children with HCM, especially in the case of a family history of sudden death

What is the relationship between increased lymphocyte infiltration, edema, and inflammation in the progression of pathophysiology in Kawasaki disease? 1. Lymphocytes initiate an immune response against invading bacteria in the blood. This immune response leads to inflammation and edema. 2. Lymphocytes attack virus-infected cells leading to edema and inflammation. This leads to the development of emboli and myocardial infarction. 3. Lymphocytes attack the endothelial cells lining the arteries. This leads to inflammation and leaky vessels that cause edema and the formation of aneurysms. 4. Lymphocytes initiate an immune response against smooth muscle cells of the vasculature causing inflammation & edema; this leads to the development of aneurysms.

4 1. Lymphocytes initiate an immune response against invading bacteria in the blood. This immune response leads to inflammation and edema. Bacteria are not the cause of Kawasaki disease. When a child with suspected KD presents with fever, antibiotic treatment will not decrease the fever. 2. Lymphocytes attack virus-infected cells leading to edema and inflammation. This leads to the development of emboli and myocardial infarction. KD has unknown etiology. No virus has been identified as the cause of this disease. 3. Lymphocytes attack the endothelial cells lining the arteries. This leads to inflammation and leaky vessels that cause edema and the formation of aneurysms. Endothelial cells are not the target of lymphocytes in Kawasaki disease. 4. Lymphocytes initiate an immune response against smooth muscle cells of the vasculature causing inflammation & edema; this leads to the development of aneurysms. After the immune response is initiated, inflammation occurs affecting all layers of medium size vessels including the coronary arteries. Overtime this leads to structural breakdown and dilation leading to the formation of the aneurysm.

Which factor influence the amount of blood that fills the ventricle immediately before contraction? 1. Hypoxia 2. Afterload 3.Body Temperature 4. Rate of venous return

4. 1. Hypoxia Hypoxia may influence contractility, or the squeezing force of the heart, but does not directly affect afterload. 2. Afterload Although afterload can affect the stroke volume, or the amount of blood pumped out of the heart with each beat, it does not directly affect preload, or the amount of blood that fills the ventricles prior to contraction. 3.Body temperature Body temperature may influence heart rate, or the number of beats per minute, but does not directly affect preload. 4.Rate of venous return Rate of venous return influences preload by altering the amount of blood returning to the heart.

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