Assessment Exam A+ Pass
Loud, harsh murmur that is not usually audible until pulmonary pressures drop at about
4 to 8 weeks of age; Heart failure; Failure to thrive; Small, possibly asymptomatic
defects. - Answers -✔✔ Ventricular septal defect (VSD)
Systolic ejection murmur; Right ventricular enlargement; Exercise intolerance; Cyanosis
with severe narrowing. - Answers -✔✔ pulmonary stenosis
Murmur; Cyanosis, severe dyspnea, clubbing of the fingers, hyper cyanotic spells, and
acidosis; Polycythemia, clot formation; frequently sits in a squatting position (decreases
venous return); Failure to thrive and growth retardation. - Answers -✔✔ tetralogy of
fallout
Increased blood pressure and oxygen saturation in the upper extremities compared to
the lower extremities; Nosebleeds; Headaches, vertigo, leg pain, weak or absent lower
extremity pulses (indicate decreased cardiac output). - Answers -✔✔ coarctation of the
aorta
Loud, harsh murmur; Mild heart failure; Possible enlarged right atrium; increased
oxygen saturations in the right atrium; Asymptomatic (possibly). - Answers -✔✔ atrial
septal defects (ASD)
Murmur (machine-hum); Wide pulse pressure; Bounding pulses; Asymptomatic
(possibly). - Answers -✔✔ patent ductus
View dying as temporary because they have no concept of time and because the dead
person may still have attributes of the living (sleeping, eating, breathing). - Answers -
✔✔ preschool children
Have egocentric thinking that prevents them from understanding death. - Answers -✔✔
toddlers
Experience fear of the disease process, the death process, the unknown, and loss of
control. - Answers -✔✔ school age children
May have difficulty accepting death because they are discovering who they are,
establishing an identity, and dealing with issues of puberty. - Answers -✔✔ adolescents
A nurse is caring for a 6-month-old infant following surgery. Which of the following
should the nurse use to measure pain in this client?
, Select one:
a. Oucher numeric scale.
b. Wong-Baker faces pain rating scale.
c. FLACC pain scale.
d. There is no special pain scale for infants. - Answers -✔✔ FLACC pain scale
A nurse is caring for an infant following a cleft lip and palate repair. Which of the
following actions should the nurse take in the post-operative period?
Select one:
a. Encourage the use of a pacifier.
b. Provide hard toys.
c. Administer analgesics.
d. Assess incision using tongue blade. - Answers -✔✔ administer analgesics
Holding a soft rattle - Answers -✔✔ 3-6 months
Watching black-and-white mobiles - Answers -✔✔ birth to 3 months
Playing peek-a-boo - Answers -✔✔ 6-9 months
Drawing, painting, riding a tricycle - Answers -✔✔ preschooler
Team sports - Answers -✔✔ school age children
Banging large block - Answers -✔✔ 9-12 months
Industry vs Inferiority - Answers -✔✔ toddler 1-3 years
Initiative vs. Guilt - Answers -✔✔ preschooler 3-6 years
Autonomy vs. Shame and Doubt - Answers -✔✔ toddler 1-3 years
Identity vs Role Confusion - Answers -✔✔ adolescent 13-20 years
Trust vs. Mistrust - Answers -✔✔ infant birth- 1 year
A nurse is caring for a child with a closed head injury. Which of the following
interventions should the nurse institute to decrease intracranial pressure? Select all that
apply.
Select one or more:
a. Provide a calm, restful environment.