The nurse is caring for a newly-admitted infant diagnosed with "failure to thrive." The nurse begins to implement the healthcare provider prescribed orders by taking blood pressures in all four extremities. Which congenital cardiac defect does the nurse anticipate based on the prescribed order?

Pulmonary atresia

Tetralogy of Fallot

Ventricular septal defect

Coarctation of the aorta

Answer and Explanation

The Correct Answer is D

A. Pulmonary atresia involves a blockage of blood flow to the lungs, but it does not specifically lead to differences in blood pressure in the extremities.

B. Tetralogy of Fallot involves four defects, but it does not directly correlate with differences in blood pressure between the extremities.

C. A ventricular septal defect can cause heart failure, but it typically doesn’t affect blood pressure in the extremities.

D. Coarctation of the aorta is a congenital defect where the aorta is narrowed, leading to higher blood pressure in the upper extremities and lower blood pressure in the lower extremities. This is why blood pressures are measured in all four extremities to identify this condition.

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Correct Answer is B

Explanation

A. Providing a detailed description of how burns occurred may suggest a plausible explanation, but it does not necessarily indicate abuse.

B. Denying discomfort despite the presence of burns may suggest emotional detachment or an attempt to conceal the severity of the injuries, which can be indicative of abuse.

C. Describing strong relationships with peers is a typical and healthy sign of social development and does not indicate abuse.

D. Reluctance to leave home may suggest anxiety or attachment to family, but it is not necessarily indicative of abuse.

A. Help the child accept the loss of control associated with hospitalization. B. Help the child accept pain that is connected with a treatment or procedure. C. Prepare the child before any unfamiliar treatment or procedure. D. Prepare the child for separation from parents during hospitalization by reviewing a video.

Correct Answer is C

Explanation

A. Rather than helping the child accept a loss of control, atraumatic care focuses on empowering the child and promoting a sense of control through participation in care and decision-making.

B. While pain management is crucial, the goal is not to have the child "accept" pain but to minimize it through interventions like distraction, pharmacologic pain relief, and comfort measures.

C. Preparing the child for unfamiliar treatments or procedures aligns with the principles of atraumatic care, which aim to reduce fear, anxiety, and physical and emotional distress. By offering developmentally appropriate explanations, the nurse helps the child feel more in control and reduces the traumatic impact of the experience.

D. Atraumatic care emphasizes maintaining parental involvement during hospitalization whenever possible. Preparing the child for separation does not align with atraumatic care principles, as separation is a source of stress that should be minimized.

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The nurse is caring for a newly-admitted infant diagnosed with "failure to thrive." The nurse begins to implement the healthcare provider prescribed orders by taking blood pressures in all four extremities. Which congenital cardiac defect does the nurse anticipate based on the prescribed order?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A school nurse is taking care of an adolescent who presents with multiple burns in various stages of healing. which of the following behaviors should the nurse identify as a suggestive of possible physical abuse?

Correct Answer is B

Explanation

Which intervention would the nurse include when providing atraumatic care?

Correct Answer is C

Explanation

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