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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Correct Answer is C

Explanation

a) Observing the child in the classroom to see interactions between the child and others: Useful for gathering information but not an initial assessment that might directly relate to the child's performance issues.

b) Determine if there is conflict between the child and the teacher: Conflict might contribute, but initial assessments should focus on other potential factors.

c) Conducting a vision and hearing screening: Sensory impairments can significantly impact a child's academic performance and are important to rule out initially.

d) Talking with the child to determine if there are family stressors such as divorce interfering with the child's performance: Valuable but might not be the first step in assessing academic performance issues.

A. Health assessment B. Health promotion C. Health maintenance D. Health screening

Correct Answer is B

Explanation

a) Health assessment: Refers to the evaluation of the child's health status, including physical examinations and assessments.

b) Health promotion: Involves educating and encouraging practices that enhance overall health, like explaining the importance of immunizations.

c) Health maintenance: Focuses on ensuring continued health through preventive measures and routine care.

d) Health screening: Involves checking for diseases or conditions even when symptoms are not apparent, typically via tests or exams.

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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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