A nurse has admitted a child with ventricular septal defect (VSD) to the unit. Which nursing diagnosis is appropriate for this child?

Hypothermia related to decreased metabolic state

Acute pain related to the effects of a congenital heart defect

Ineffective tissue perfusion (peripheral) related to cyanosis secondary to congenital heart defect

Impaired gas exchange related to pulmonary congestion secondary to the increased pulmonary blood flow

Answer and Explanation

The Correct Answer is C

a) Hypothermia related to decreased metabolic state: Unlikely to be directly related to VSD unless it's causing severe complications affecting metabolic function.

b) Acute pain related to the effects of a congenital heart defect: While the child might experience pain due to surgery or interventions, it's not the primary nursing diagnosis for VSD.

c) Ineffective tissue perfusion (peripheral) related to cyanosis secondary to congenital heart defect: VSD causes increased workload on the heart, leading to decreased oxygenation and potentially causing cyanosis and ineffective tissue perfusion.

d) Impaired gas exchange related to pulmonary congestion secondary to the increased pulmonary blood flow: While pulmonary congestion can occur, ineffective tissue perfusion is more directly related to cyanosis from VSD.

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Free Nursing Study Resources

Correct Answer is A

Explanation

a) Hug his teddy bear when he coughs: Splinting the chest while coughing can reduce discomfort.

b) Blow bubbles to prevent coughing episodes: Not effective for reducing cough-induced pain.

c) Take a sip of apple juice before coughing: Drinking before coughing may not significantly alleviate the discomfort.

d) Ask for codeine cough syrup when he coughs: Medication should be given based on medical advice and prescription, not as a self-request by a child.

A. IgM B. IgA C. IgG D. IgE

Correct Answer is C

Explanation

a) IgM: Typically does not cross the placenta in significant amounts.

b) IgA: Does not pass through the placenta.

c) IgG: Crosses the placenta, providing passive immunity to the fetus.

d) IgE: Does not significantly cross the placenta barrier.

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A nurse has admitted a child with ventricular septal defect (VSD) to the unit. Which nursing diagnosis is appropriate for this child?

Nursing Test Bank

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Correct Answer is C

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