Which nursing diagnoses are appropriate for an infant with a large patent ductus arteriosus (PDA)?
Risk for infection.
Decreased cardiac output.
Fluid volume deficit.
Risk for impaired gas exchange.
Activity intolerance.
Correct Answer : B,D,E
Choice A rationale
Risk for infection is a generalized diagnosis and is not specific to the hemodynamic consequences of a large patent ductus arteriosus (PDA). The primary pathophysiology involves a left-to-right shunting of oxygenated blood leading to pulmonary overcirculation and systemic underperfusion, which are more critical issues.
Choice B rationale
A large PDA allows a significant volume of blood to shunt from the aorta (higher pressure) to the pulmonary artery (lower pressure). This diversion of systemic blood volume results in decreased systemic cardiac output and perfusion, leading to compensatory tachycardia and eventual heart failure.
Choice C rationale
Fluid volume deficit is incorrect. The left-to-right shunting in a large PDA causes increased pulmonary blood flow and pressure, leading to pulmonary congestion, which can manifest as fluid volume excess in the lungs and sometimes systemically, not a deficit.
Choice D rationale
The excessive blood flow shunting to the lungs due to a large PDA causes pulmonary overcirculation and pressure increase. This over-perfusion impairs alveolar-capillary gas exchange dynamics, leading to pulmonary edema and ventilation-perfusion mismatch, increasing the risk for impaired gas exchange.
Choice E rationale
The chronic strain on the heart from the increased volume and pressure load due to the large left-to-right shunt requires increased myocardial work. This leads to cardiac muscle fatigue and an inability to meet the body's metabolic demands during exertion, resulting in activity intolerance and poor weight gain.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale
Hypercyanotic spells, or "tet spells," result from a sudden decrease in pulmonary blood flow and increased right-to-left shunting, leading to profound hypoxemia. Administering oxygen helps by slightly increasing arterial oxygen tension, which acts as a mild pulmonary vasodilator, potentially reducing pulmonary vascular resistance and improving oxygen delivery to tissues. This aims to counteract the immediate hypoxemia.
Choice C rationale
Morphine administration is appropriate because of its central nervous system depressant effects. It helps to calm the infant, decreasing systemic oxygen demands and reducing the hyperpnea (rapid, deep breathing) that often accompanies the spell. Furthermore, morphine mildly vasodilates, which increases systemic vascular resistance, decreasing the right-to-left shunt flow.
Choice E rationale
Placing the infant in the knee-chest position significantly increases systemic vascular resistance (SVR) by compressing the major arteries in the lower extremities. The increased SVR reduces the pressure gradient driving the right-to-left shunt through the ventricular septal defect, thereby increasing pulmonary blood flow and improving oxygen saturation during the hypercyanotic event.
Correct Answer is A
Explanation
Choice A rationale
The constellation of fever (101.5°F or 38.6°C), irritability, and tachycardia (160 bpm, normal for a 2-year-old is ∼80-130 bpm) in a child with a ventricular shunt is highly suggestive of a shunt infection (ventriculitis or meningitis). A shunt infection can lead to septicemia and shunt malfunction, potentially causing rapidly increased intracranial pressure (ICP). Given the high morbidity, this finding requires immediate notification of the provider for prompt diagnostic workup (e.g., shunt tap) and empiric antibiotics.
Choice B rationale
While tachycardia and irritability can sometimes be non-specific symptoms, a fever of 101.5°F is abnormal. The presence of a ventricular shunt significantly raises the index of suspicion for shunt infection, a neurosurgical emergency, which is a life-threatening condition. Documenting and observing without immediate intervention is dangerously negligent given the clinical picture.
Choice C rationale
Administering antipyretics addresses only the fever, a symptom, and does not treat the underlying potentially fatal shunt infection. Delaying notification to reassess in one hour risks rapid neurological deterioration, as shunt infections can progress quickly to sepsis, severe ventriculitis, or uncompensated increased intracranial pressure (ICP). Immediate medical evaluation is the priority.
Choice D rationale
Encouraging oral fluids is a supportive measure for fever and dehydration, but it is not the priority for a child highly suspected of having a ventricular shunt infection. Oral fluid intake can be impaired due to irritability and potential nausea/vomiting associated with increased intracranial pressure, and this action delays definitive diagnosis and treatment of the infection.
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