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A nurse is assessing a client who has been diagnosed with Atrial septal defect (ASD).
The client reports difficulty breathing (dyspnea), frequent respiratory infections, feeling the heart beat (palpitations), and shortness of breath with activity.
During auscultation, the nurse hears a systolic ejection murmur that is best heard at the left upper sternal border.
Which of the following nursing interventions are appropriate for this client? Select all that apply.

Monitor vital signs regularly.

Administer prescribed medications.

Encourage bed rest.

Provide oxygen therapy as needed.

Educate the client about lifestyle modifications.

Answer and Explanation

Correct Answer : A,B,D,E

Choice A rationale:

Monitor vital signs regularly.

This is an appropriate nursing intervention for a client with Atrial septal defect (ASD).

Regular monitoring of vital signs, including heart rate and blood pressure, helps to assess the client's cardiovascular status and response to treatment.

Choice B rationale:

Administer prescribed medications.

Administering medications as prescribed is a crucial nursing intervention.

Depending on the client's condition, medications may include diuretics, antiarrhythmics, or other medications to manage symptoms and improve heart function.

Choice C rationale:

Encourage bed rest.

Encouraging bed rest is not typically required for clients with ASD unless there are specific indications, such as severe symptoms.

It's important to promote activity within the limits of the client's condition to prevent deconditioning.

Choice D rationale:

Provide oxygen therapy as needed.

Oxygen therapy may be needed for clients with ASD if they experience significant hypoxia or respiratory distress.

It can help improve oxygen saturation and relieve dyspnea.

Choice E rationale:

Educate the client about lifestyle modifications.

Educating the client about lifestyle modifications is essential.

Clients with ASD may benefit from lifestyle changes such as a heart-healthy diet, regular exercise within their limits, and smoking cessation if applicable.

These modifications can help manage symptoms and improve overall cardiovascular health.

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Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale:

Bluish discoloration of the skin, lips, or nail beds (cyanosis) is a classic symptom of cyanotic congenital heart disease (CCHD).

This occurs because of the inadequate oxygenation of the blood, which leads to oxygen-poor blood being circulated in the body.

Choice B rationale:

Poor feeding and inadequate weight gain can be associated with CCHD, especially when there is a significant reduction in cardiac output.

Infants with CCHD may have difficulty feeding due to the increased workload on their heart and may struggle to gain weight.

Choice C rationale:

Rapid breathing and shortness of breath are common symptoms in children with CCHD.

The inadequate oxygenation of the blood can lead to an increased respiratory rate and shortness of breath as the body tries to compensate for the lack of oxygen.

Choice D rationale:

Abnormal heart sounds heard during auscultation are characteristic of CCHD.

The specific type of abnormal heart sound may vary depending on the specific defect but can include murmurs, clicks, or other unusual sounds.

Choice E rationale:

Frequent respiratory infections are not typically associated with CCHD.

While children with CCHD may be more susceptible to infections due to their compromised oxygenation, it is not a direct symptom of the condition.

A. "It helps assess the electrical activity of the heart.” B. "It evaluates the child's respiratory rate and effort.” C. "It monitors oxygen saturation using pulse oximetry.” D. "It measures the child's weight and developmental milestones.”

Correct Answer is C

Explanation

Choice A rationale:

Measuring the level of oxygen in a child's blood does not help assess the electrical activity of the heart.

Oxygen measurement and the assessment of heart electrical activity are two separate concepts.

Choice B rationale:

Measuring oxygen levels in the blood primarily evaluates the child's oxygen saturation, not the respiratory rate and effort.

While oxygen saturation is related to respiratory function, it doesn't directly assess the rate and effort of breathing.

Choice C rationale:

Measuring the level of oxygen in a child's blood monitors oxygen saturation using pulse oximetry.

Pulse oximetry is a non-invasive method used to measure the percentage of oxygen saturation in the blood.

This is important because it provides information about the child's oxygen levels, which is crucial for assessing their respiratory and circulatory status.

Choice D rationale:

Measuring the level of oxygen in the blood does not measure the child's weight and developmental milestones.

This response is unrelated to the purpose of monitoring oxygen levels in the blood.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Select all the symptoms that may be associated with cyanotic congenital heart disease (CCHD) in children.

Correct Answer is ["A","B","C","D"]

Explanation

A client asks the nurse, "What is the purpose of measuring the level of oxygen in my child's blood?" Which response by the nurse is accurate?

Correct Answer is C

Explanation

A client has a child with a congenital heart defect and is concerned about the child's medication.What statement by the client indicates a need for further education about medication management?

A nurse is caring for a child with a suspected congenital heart defect.Which diagnostic test is most appropriate for assessing the size and shape of the heart and detecting associated abnormalities?

A client is inquiring about the long-term management of their child's congenital heart defect.What information should the nurse provide regarding follow-up care?

A client has a child diagnosed with Tetralogy of Fallot (TOF) and is concerned about the child's symptoms.Which of the following symptoms are characteristic of TOF?

A nurse is providing nursing interventions for a child with a congenital heart defect.What is an example of a medication that may be administered as prescribed to this child?

(Select all that apply): A nurse is educating a group of parents about congenital heart defects in children.Which factors may contribute to the development of congenital heart defects in children? Select all that apply.