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A client is admitted to the hospital with a systolic ejection murmur that is best heard at the left upper sternal border.
The client has no other symptoms and is otherwise healthy.
The client asks the nurse, "What does this murmur mean?".
The nurse's best response is:.

"This murmur is a sign of a heart defect called coarctation of the aorta (COA).”

"This murmur is a sign of a heart defect called atrial septal defect (ASD).”

"This murmur is a sign of a heart defect called ventricular septal defect (VSD).”

"This murmur is a sign of a heart defect called tetralogy of Fallot (TOF).”

Answer and Explanation

The Correct Answer is A

"This murmur is a sign of a heart defect called coarctation of the aorta (COA).”.

Choice A rationale:

"This murmur is a sign of a heart defect called coarctation of the aorta (COA).”.

A systolic ejection murmur heard at the left upper sternal border can be indicative of coarctation of the aorta (COA).

Coarctation of the aorta is a congenital heart defect characterized by a narrowing or constriction of the aorta, typically near the site of the ductus arteriosus.

This narrowing leads to increased pressure and turbulence in the left ventricle and aorta, resulting in the systolic ejection murmur.

Informing the client about the likely diagnosis is a good approach as it helps provide them with essential information about their condition.

Choice B rationale:

"This murmur is a sign of a heart defect called atrial septal defect (ASD).”.

An atrial septal defect (ASD) typically presents with a different type of murmur, not a systolic ejection murmur heard at the left upper sternal border.

ASD is characterized by a fixed, split second heart sound (S2) and a mid-systolic murmur at the upper left sternal border.

The description in the question does not align with the typical findings of an ASD.

Choice C rationale:

"This murmur is a sign of a heart defect called ventricular septal defect (VSD).”.

A ventricular septal defect (VSD) also presents with a different type of murmur, typically a harsh holosystolic murmur heard at the lower left sternal border.

The description of the murmur in the question, a systolic ejection murmur at the left upper sternal border, is not characteristic of a VSD.

Choice D rationale:

"This murmur is a sign of a heart defect called tetralogy of Fallot (TOF).”.

Tetralogy of Fallot (TOF) is characterized by a different set of heart defects, including a ventricular septal defect (VSD), overriding aorta, right ventricular outflow tract obstruction, and right ventricular hypertrophy.

The murmur described in the question is not specific to TOF and is more indicative of coarctation of the aorta (COA) due to its location and characteristics.

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Correct Answer is C

Explanation

Choice A rationale:

Measuring the level of oxygen in a child's blood does not help assess the electrical activity of the heart.

Oxygen measurement and the assessment of heart electrical activity are two separate concepts.

Choice B rationale:

Measuring oxygen levels in the blood primarily evaluates the child's oxygen saturation, not the respiratory rate and effort.

While oxygen saturation is related to respiratory function, it doesn't directly assess the rate and effort of breathing.

Choice C rationale:

Measuring the level of oxygen in a child's blood monitors oxygen saturation using pulse oximetry.

Pulse oximetry is a non-invasive method used to measure the percentage of oxygen saturation in the blood.

This is important because it provides information about the child's oxygen levels, which is crucial for assessing their respiratory and circulatory status.

Choice D rationale:

Measuring the level of oxygen in the blood does not measure the child's weight and developmental milestones.

This response is unrelated to the purpose of monitoring oxygen levels in the blood.

A. "It's essential to schedule cardiac rehabilitation sessions for your child.” B. "Long-term monitoring will include regular follow-up appointments with the cardiologist.” C. "You can discontinue all medications once your child reaches a certain age.” D. "Balloon valvuloplasty will be the primary treatment for long-term management.”

Correct Answer is B

Explanation

"Long-term monitoring will include regular follow-up appointments with the cardiologist.”.

Choice A rationale:

Stating, "It's essential to schedule cardiac rehabilitation sessions for your child," is not accurate for the long-term management of a congenital heart defect.

Cardiac rehabilitation is typically recommended for individuals who have experienced a cardiac event, such as a heart attack, but it is not a standard part of the long-term management of congenital heart defects in children.

Choice B rationale:

Informing the client that long-term monitoring will include regular follow-up appointments with the cardiologist is The correct nursing response.

Regular follow-up appointments are essential for monitoring the child's heart condition, adjusting treatment as needed, and ensuring their overall well-being.

This choice is accurate and aligned with best practices.

Choice C rationale:

Stating, "You can discontinue all medications once your child reaches a certain age," is not accurate or safe advice.

The need for medications in the management of a congenital heart defect is determined by the child's specific condition and the recommendations of the healthcare team.

Discontinuing medications without medical guidance can be dangerous and is not a standard practice.

Choice D rationale:

Claiming, "Balloon valvuloplasty will be the primary treatment for long-term management," is not a universally applicable statement.

The choice of treatment for long-term management of a congenital heart defect depends on the specific diagnosis and clinical circumstances.

While balloon valvuloplasty may be a suitable treatment in some cases, it is not the primary treatment for all congenital heart defects.

Individualized care plans are developed based on the child's condition.

Therefore, this statement is not accurate as a general rule.

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A client is admitted to the hospital with a systolic ejection murmur that is best heard at the left upper sternal border.The client has no other symptoms and is otherwise healthy.The client asks the nurse, "What does this murmur mean?".The nurse's best response is:.

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Naxlex Comprehensive Predictor Exams

A client asks the nurse, "What is the purpose of measuring the level of oxygen in my child's blood?" Which response by the nurse is accurate?

Correct Answer is C

Explanation

A client is inquiring about the long-term management of their child's congenital heart defect.What information should the nurse provide regarding follow-up care?

Correct Answer is B

Explanation

A client asks the nurse, "How can I optimize my child's respiratory function?" What should the nurse's response include?

A client has a child diagnosed with Tetralogy of Fallot (TOF) and is concerned about the child's symptoms.Which of the following symptoms are characteristic of TOF?

A nurse is caring for a child diagnosed with Ventricular septal defect (VSD).The child presents with poor feeding, fast breathing, and sweating with exertion.Which of the following is the characteristic heart murmur associated with VSD?

A nurse is caring for an infant with cyanosis and a ventricular septal defect (VSD).The nurse should expect which of the following symptoms in this patient?

(Select all that apply): A nurse is educating a group of parents about congenital heart defects in children.Which factors may contribute to the development of congenital heart defects in children? Select all that apply.

A nurse caring for a child with a congenital heart defect is performing a physical examination.Which statement reflects an appropriate action during the assessment?

A nurse is caring for a child with a suspected congenital heart defect.Which diagnostic test is most appropriate for assessing the size and shape of the heart and detecting associated abnormalities?

A client is admitted to the hospital with a systolic ejection murmur that is best heard at the left upper sternal border.
The client has no other symptoms and is otherwise healthy.
The client asks the nurse, "What does this murmur mean?".
The nurse's best response is:.