Ricci Chapter 41 - Test Bank - 4th Edition
questions and answers graded A+
1.The nurse is conducting a physical examination of a child with a ventricular septal
defect. Which finding would the nurse expect to assess?
A) Right ventricular heave
B) Holosystolic harsh murmur along the left sternal border
C) Fixed split-second heart sound
D) Systolic ejection murmur - correct answer ✔✔Ans: B
Feedback:
With ventricular septal defects, there is often a characteristic holosystolic harsh
murmur along the left sternal border. Right ventricular heave, fixed split-second
heart sound, and systolic ejection murmur are typically found with atrial septal
defects.
2.The nurse is administering digoxin as ordered and the child vomits the dose. What
should the nurse do next?
A) Contact the healthcare provider.
B) Offer a snack and administer another dose.
C) Immediately administer another dose.
D) Administer next dose as ordered in 12 hours. - correct answer ✔✔Ans: D
Feedback:
Digoxin should be administered at regular intervals, every 12 hours, 1 hour before or
2 hours after feeding. If the child vomits digoxin, the nurse should not give a second
dose and should wait until the next scheduled dose. It is not necessary to contact the
,healthcare provider.
3.The nurse is caring for an infant with suspected patent ductus arteriosus. Which
assessment finding would the nurse identify as helping to confirm this suspicion?
A) Thrill at the base of the heart
B) Harsh, continuous, machine-like murmur under the left clavicle
C) Faint pulses
D) Systolic murmur best heard along the left sternal border - correct answer ✔✔Ans: B
Feedback:
With patent ductus arteriosus, a harsh, continuous, machine-like murmur (usually
loudest under the left clavicle) is heard at the first and second intercostal spaces. A
thrill at the base, faint pulses, and systolic murmur heard best along the left sternal
border point to aortic stenosis.
4.The nurse is conducting a physical examination of a child with a suspected
cardiovascular disorder. Which finding would the nurse most likely expect to assess
if the child had transposition of the great vessels?
A) Significant cyanosis without presence of a murmur
B) Abrupt cessation of chest output with an increase in heart rate/filling
pressure
C) Soft systolic ejection
D) Holosystolic murmur - correct answer ✔✔Ans: A
Feedback:
Significant cyanosis without presence of a murmur is highly indicative of
transposition. Abrupt cessation of chest output accompanied by an increase in heart rate and
filling pressure is indicative of cardiac tamponade. A soft systolic ejection or
, holosystolic murmur can be found with other disorders, such as hypoplastic left heart
syndrome, but is not highly suspicious of transposition.
5.The nurse is assessing a child with suspected infective endocarditis. Which
assessment finding would the nurse interpret as a sign of extracardiac emboli?
A) Pruritus
B) Roth spots
C) Delayed capillary refill
D) Erythema marginatum - correct answer ✔✔Ans: B
Feedback:
Roth spots are splinter hemorrhages with pale centers on the sclerae, palate, buccal
mucosa, chest, fingers, or toes, and are signs of extracardiac emboli. Delayed
capillary refill time does not point to extracardiac emboli. Wheezing and pruritus are
indicative of a hypersensitivity reaction. Erythema marginatum is a classic rash
associated with acute rheumatic fever.
6.When conducting a physical examination of a child with suspected Kawasaki
disease, which finding would the nurse expect to assess?
A) Hirsutism or striae
B) Strawberry tongue
C) Malar rash
D) Café au lait spots - correct answer ✔✔Ans: B
Feedback:
Dry, fissured lips and a strawberry tongue are common findings with Kawasaki
disease. Acne, hirsutism, and striae are associated with anabolic steroid use. Malar
rash is associated with lupus. Café au lait spots are associated with
questions and answers graded A+
1.The nurse is conducting a physical examination of a child with a ventricular septal
defect. Which finding would the nurse expect to assess?
A) Right ventricular heave
B) Holosystolic harsh murmur along the left sternal border
C) Fixed split-second heart sound
D) Systolic ejection murmur - correct answer ✔✔Ans: B
Feedback:
With ventricular septal defects, there is often a characteristic holosystolic harsh
murmur along the left sternal border. Right ventricular heave, fixed split-second
heart sound, and systolic ejection murmur are typically found with atrial septal
defects.
2.The nurse is administering digoxin as ordered and the child vomits the dose. What
should the nurse do next?
A) Contact the healthcare provider.
B) Offer a snack and administer another dose.
C) Immediately administer another dose.
D) Administer next dose as ordered in 12 hours. - correct answer ✔✔Ans: D
Feedback:
Digoxin should be administered at regular intervals, every 12 hours, 1 hour before or
2 hours after feeding. If the child vomits digoxin, the nurse should not give a second
dose and should wait until the next scheduled dose. It is not necessary to contact the
,healthcare provider.
3.The nurse is caring for an infant with suspected patent ductus arteriosus. Which
assessment finding would the nurse identify as helping to confirm this suspicion?
A) Thrill at the base of the heart
B) Harsh, continuous, machine-like murmur under the left clavicle
C) Faint pulses
D) Systolic murmur best heard along the left sternal border - correct answer ✔✔Ans: B
Feedback:
With patent ductus arteriosus, a harsh, continuous, machine-like murmur (usually
loudest under the left clavicle) is heard at the first and second intercostal spaces. A
thrill at the base, faint pulses, and systolic murmur heard best along the left sternal
border point to aortic stenosis.
4.The nurse is conducting a physical examination of a child with a suspected
cardiovascular disorder. Which finding would the nurse most likely expect to assess
if the child had transposition of the great vessels?
A) Significant cyanosis without presence of a murmur
B) Abrupt cessation of chest output with an increase in heart rate/filling
pressure
C) Soft systolic ejection
D) Holosystolic murmur - correct answer ✔✔Ans: A
Feedback:
Significant cyanosis without presence of a murmur is highly indicative of
transposition. Abrupt cessation of chest output accompanied by an increase in heart rate and
filling pressure is indicative of cardiac tamponade. A soft systolic ejection or
, holosystolic murmur can be found with other disorders, such as hypoplastic left heart
syndrome, but is not highly suspicious of transposition.
5.The nurse is assessing a child with suspected infective endocarditis. Which
assessment finding would the nurse interpret as a sign of extracardiac emboli?
A) Pruritus
B) Roth spots
C) Delayed capillary refill
D) Erythema marginatum - correct answer ✔✔Ans: B
Feedback:
Roth spots are splinter hemorrhages with pale centers on the sclerae, palate, buccal
mucosa, chest, fingers, or toes, and are signs of extracardiac emboli. Delayed
capillary refill time does not point to extracardiac emboli. Wheezing and pruritus are
indicative of a hypersensitivity reaction. Erythema marginatum is a classic rash
associated with acute rheumatic fever.
6.When conducting a physical examination of a child with suspected Kawasaki
disease, which finding would the nurse expect to assess?
A) Hirsutism or striae
B) Strawberry tongue
C) Malar rash
D) Café au lait spots - correct answer ✔✔Ans: B
Feedback:
Dry, fissured lips and a strawberry tongue are common findings with Kawasaki
disease. Acne, hirsutism, and striae are associated with anabolic steroid use. Malar
rash is associated with lupus. Café au lait spots are associated with
