A nurse is assessing a 3-year-old client who has been diagnosed with an Atrial Septal Defect (ASD). Which of the following findings should the nurse expect? (Select All That Apply)
Right Atrial Enlargement
Left Atrial Enlargement
Shortness of breath.
Pulmonary hypertension
Pulmonary hypotension
Correct Answer : A,C,D
A. Right atrial enlargement occurs due to the increased blood flow from left to right shunting, which can cause volume overload in the right atrium.
B. Left atrial enlargement is typically seen in conditions that cause increased left atrial pressure, such as mitral valve disease or left-sided heart failure, not in ASD.
C. Shortness of breath is a common symptom due to increased blood flow to the lungs, which can lead to pulmonary congestion.
D. Pulmonary hypertension may develop over time due to increased blood flow and pressure in the pulmonary circulation from the left-to-right shunting of blood.
E. Pulmonary hypotension is not associated with ASD. The condition typically leads to increased pressure in the pulmonary arteries, not decreased pressure
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This is important for mobility, but after casting, the priority is to monitor for complications such as compartment syndrome, which can be life-threatening if not addressed.
B. While body image and emotional well-being are important, the priority immediately following a fracture and cast placement is physical monitoring for complications.
C. Worsening pain after a fracture or cast placement may indicate complications such as compartment syndrome, a medical emergency that requires prompt intervention. Monitoring for signs of increased pain is crucial.
D. Range of motion is a later consideration after ensuring the child does not have complications such as compartment syndrome. The priority is evaluating the affected limb for issues like worsening pain or signs of nerve damage.
Correct Answer is C
Explanation
A. While hydration is important to help with blood flow, pain management takes precedence during an SCD crisis.
B. Oxygen may be necessary in certain cases but is not the priority in the acute pain crisis, where pain control is the primary concern.
C. Pain management is the priority in sickle cell disease (SCD) crisis, as it helps alleviate the intense pain associated with vaso-occlusive events.
D. Antipyretics are not the priority unless the child has a fever. Pain relief is more urgent during a crisis.
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