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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A continuous "machinery" murmur that is loudest below the left clavicle is typically associated with a patent ductus arteriosus (PDA), not VSD.
PDA is a different congenital heart defect.
Choice B rationale:
A harsh holosystolic murmur that is best heard at the left lower sternal border is the characteristic murmur associated with Ventricular Septal Defect (VSD).
This murmur is caused by the blood flowing from the high-pressure left ventricle to the low-pressure right ventricle through the VSD hole throughout the cardiac cycle.
Choice C rationale:
A systolic ejection murmur that is best heard at the left upper sternal border is often associated with aortic stenosis, not VSD.
Choice D rationale:
A systolic ejection murmur that radiates to the back is characteristic of aortic regurgitation, which is a different cardiac condition.
The characteristic heart murmur in VSD is the result of blood flowing from the left ventricle to the right ventricle through the VSD hole during systole.
This causes a harsh holosystolic murmur, which is loudest at the left lower sternal border due to the location of the defect in the ventricular septum.
Therefore, choice B is The correct answer.
Correct Answer is A
Explanation
Choice A rationale:
Checking the child's oxygen saturation using a pulse oximeter is an appropriate action during the assessment of a child with a congenital heart defect.
Oxygen saturation monitoring helps assess the child's oxygen levels, which is crucial in determining the adequacy of oxygen supply to the body.
Children with congenital heart defects are at risk of reduced oxygen levels, and monitoring oxygen saturation is a vital part of their care.
Choice B rationale:
Ensuring the child receives all their vaccinations is important for the child's overall health but is not directly related to the assessment of a congenital heart defect.
Vaccinations are typically administered as part of routine healthcare, but they do not address the specific concerns related to a congenital heart defect assessment.
Choice C rationale:
Assessing the child's neurological development is important but is not the primary focus of the assessment for a congenital heart defect.
While neurological assessment is important for overall child development, it does not directly relate to the cardiac assessment.
Choice D rationale:
Monitoring the child's growth based on height alone is not a comprehensive assessment for a child with a congenital heart defect.
Monitoring growth should include various parameters, such as weight, head circumference, and developmental milestones.
Relying solely on height may not provide a complete picture of the child's overall development.
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