A client with Ventricular septal defect (VSD) presents with signs of heart failure such as poor feeding, weight gain, or growth; fast breathing or breathlessness; easy tiring; sweating with exertion.
The nurse hears a harsh holosystolic murmur that is best heard at the left lower sternal border during auscultation.
Which of the following statements should the client make to the nurse?
"I have been feeling very tired lately and I am unable to eat properly.”
"I have been experiencing shortness of breath and rapid weight gain.”
"I have been feeling dizzy and fainting frequently.”
"I have been having severe chest pain and palpitations.”
The Correct Answer is B
Choice A rationale:
"I have been feeling very tired lately and I am unable to eat properly.”.
This choice does not address the specific symptoms associated with a Ventricular septal defect (VSD) and is not the best response to the nurse's findings.
While tiredness and poor feeding may be related to heart failure, it does not directly reflect the symptoms associated with VSD, such as breathlessness and sweating with exertion.
Choice B rationale:
"I have been experiencing shortness of breath and rapid weight gain.”.
This is The correct answer.
The symptoms of shortness of breath and rapid weight gain align with the typical presentation of a VSD.
VSD can lead to heart failure, which results in fluid retention, manifesting as rapid weight gain, and shortness of breath due to congestion in the lungs.
Choice C rationale:
"I have been feeling dizzy and fainting frequently.”.
This choice describes symptoms that can be related to various health issues, but it doesn't directly correlate with the characteristic signs of VSD.
The primary symptoms in VSD are related to heart failure, and while dizziness and fainting can occur with severe heart issues, they are not the primary indicators in this case.
Choice D rationale:
"I have been having severe chest pain and palpitations.”.
This response does not align with the typical symptoms of VSD.
While palpitations can be associated with heart issues, chest pain is not a common symptom of VSD.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Antibiotics are not specific to congenital heart defects.
While a child with a heart defect may need antibiotics in certain situations, they are not a medication that is universally prescribed for all children with heart defects.
Choice B rationale:
Anti-seizure medication is not typically prescribed for children with congenital heart defects unless there is a specific medical indication related to seizures.
It is not a standard treatment for heart defects.
Choice C rationale:
Diuretics are an example of a medication that may be prescribed to a child with a congenital heart defect.
Diuretics can help manage fluid retention, reduce the workload on the heart, and improve the child's overall condition.
Choice D rationale:
Painkillers may be prescribed for pain relief, but they are not specific to congenital heart defects.
Their use would depend on the individual circumstances and whether the child is experiencing pain.
Correct Answer is ["A","B","E"]
Explanation
Encourage regular follow-up appointments with the cardiologist.
B. Teach parents how to administer medication to the child.
E. Provide resources for support groups and counseling for the parents.
Choice A rationale:
Encouraging regular follow-up appointments with the cardiologist is essential for a child with a congenital heart defect.
These appointments allow for the monitoring of the child's heart condition, adjustments in their treatment plan, and early detection of any potential issues or complications.
Regular follow-up ensures that the child's heart health is closely monitored, which is crucial for their well-being.
Choice B rationale:
Teaching parents how to administer medication to the child is another important nursing intervention.
Many children with congenital heart defects require medications to manage their condition.
Proper administration is critical to maintaining the child's health and preventing complications.
Education empowers parents to be actively involved in their child's care, ensuring medication compliance and safety.
Choice C rationale:
Advising parents to expose the child to secondhand smoke is not appropriate.
Secondhand smoke is harmful and can have detrimental effects on a child's health, especially a child with a congenital heart defect.
It can worsen respiratory and cardiovascular problems, which is the opposite of promoting the child's well-being.
This choice should be avoided.
Choice D rationale:
Instructing parents to limit physical activity to prevent any stress on the child's heart is not a suitable nursing intervention.
While some restrictions on physical activity may be necessary, they should be determined by the cardiologist based on the child's specific condition.
Complete physical inactivity can have negative effects on a child's overall health and development.
It's important to strike a balance between physical activity and the child's heart health.
Choice E rationale:
Providing resources for support groups and counseling for the parents is an excellent nursing intervention.
Having a child with a congenital heart defect can be emotionally challenging for parents.
Support groups and counseling can offer them emotional support, guidance, and a safe space to share their concerns and experiences.
This contributes to the parents' well-being, which in turn benefits the child's care and family dynamics.
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