A client is diagnosed with an atrial septal defect (ASD).
What is a likely symptom associated with this condition?
"I've noticed a bluish discoloration of my skin and lips.”
"I find it hard to feed, and I'm not gaining weight as expected.”
"I feel short of breath and tired during physical activities.”
"The doctor mentioned hearing unusual heart sounds during the examination.”
The Correct Answer is C
Choice A rationale:
"I've noticed a bluish discoloration of my skin and lips" is not a typical symptom of an atrial septal defect (ASD).
ASD is a congenital heart defect that involves an abnormal opening between the atria of the heart, and it typically results in increased blood flow to the lungs, not cyanosis.
Choice B rationale:
"I find it hard to feed, and I'm not gaining weight as expected" can be related to ASD, but it is not a primary symptom.
The increased blood flow to the lungs in ASD may lead to congestive heart failure, which can cause poor feeding and inadequate weight gain.
Choice C rationale:
"I feel short of breath and tired during physical activities" is a likely symptom of ASD.
With ASD, there is an increased volume of blood being pumped into the lungs, which can lead to pulmonary congestion, shortness of breath, and fatigue.
Choice D rationale:
"The doctor mentioned hearing unusual heart sounds during the examination" is not a symptom but rather a sign of an atrial septal defect.
Unusual heart sounds, like a fixed split second heart sound, may be heard on auscultation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A continuous "machinery" murmur that is loudest below the left clavicle is typically associated with a patent ductus arteriosus (PDA), not VSD.
PDA is a different congenital heart defect.
Choice B rationale:
A harsh holosystolic murmur that is best heard at the left lower sternal border is the characteristic murmur associated with Ventricular Septal Defect (VSD).
This murmur is caused by the blood flowing from the high-pressure left ventricle to the low-pressure right ventricle through the VSD hole throughout the cardiac cycle.
Choice C rationale:
A systolic ejection murmur that is best heard at the left upper sternal border is often associated with aortic stenosis, not VSD.
Choice D rationale:
A systolic ejection murmur that radiates to the back is characteristic of aortic regurgitation, which is a different cardiac condition.
The characteristic heart murmur in VSD is the result of blood flowing from the left ventricle to the right ventricle through the VSD hole during systole.
This causes a harsh holosystolic murmur, which is loudest at the left lower sternal border due to the location of the defect in the ventricular septum.
Therefore, choice B is The correct answer.
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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