Test Bank Maternal Child Nursing Care,
6th Edition By Perry
Chapter 42: The Child With Cardiovascular Dysfunction
Perry: Maternal Child Nursing Care, 6th Edition
MULTIPLE CHOICE
1. Which complication should the nurse asses for when caring for a child post cardiac
catheterization?
a. Cardiac arrhythmia
b. Hypostatic pneumonia
c. Congestive heart failure
d. Rapidly increasing blood pressure
ANS: A
Because a catheter is introduced into the heart, a risk exists of catheter-induced arrhythmias
occurring during the procedure. These are usually transient. Hypostatic pneumonia,
congestive heart failure, and rapidly increasing blood pressure are not risks usually associated
with cardiac catheterization.
PTS: 1 DIF: Cognitive Level: Application
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
2. José is 4 year old. Preoperative teaching for a 4-year-old child scheduled for a cardiac
catheterization should be done with what primary consideration in mind?
a. Directed at his parents because he is too young to understand.
b. Detailed in regard to the actual procedures so he will know what to expect.
c. Done several days before the procedure so that he will be prepared.
d. Adapted to his level of development so that he can understand.
ANS: D
Preoperative teaching should always be directed at the child’s stage of development. The
caregivers also benefit from the same explanations. The parents may ask additional questions,
which should be answered, but the child needs to receive the information based on
developmental level. This age-group does not understand in-depth descriptions. Preschoolers
should be prepared close to the time of the cardiac catheterization.
PTS: 1 DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
,3. The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells
the nurse that her bandage is “too wet.” The nurse finds the bandage and bed soaked with blood.
What is the most appropriate initial nursing action?
a. Notify the physician.
b. Apply a new bandage with more pressure.
c. Place the child in the Trendelenburg position.
d. Apply direct pressure above the catheterization site.
ANS: D
If bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the
percutaneous skin site to localize pressure over the vessel puncture. Notifying the physician
and applying a new bandage with more pressure can be done after pressure is applied. The
nurse can have someone else notify the physician while the pressure is being maintained. The
Trendelenburg position would not be helpful; it would increase the drainage from the lower
extremities.
PTS: 1 DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
4. Which defect results in increased pulmonary blood flow?
a. Pulmonic stenosis
b. Tricuspid atresia
c. Atrial septal defect
d. Transposition of the great arteries
ANS: C
Atrial septal defect results in increased pulmonary blood flow. Blood flows from the left
atrium (higher pressure) into the right atrium (lower pressure) and then to the lungs via the
pulmonary artery. Pulmonic stenosis is an obstruction to blood flowing from the ventricles.
Tricuspid atresia results in decreased pulmonary blood flow. Transposition of the great
arteries results in mixed blood flow.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
5. Which structural defects constitute tetralogy of Fallot?
a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular
hypertrophy
b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
, d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular
hypertrophy
ANS: A
Tetralogy of Fallot has these four characteristics: pulmonary stenosis, ventricular septal
defect, overriding aorta, and right ventricular hypertrophy. There is pulmonic stenosis but not
aortic stenosis in tetralogy of Fallot. Right ventricular hypertrophy, not left ventricular
hypertrophy, is present in tetralogy of Fallot. There is a ventricular septal defect, not an atrial
septal defect, and overriding aorta, not aortic hypertrophy, is present.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
6. What is best described as the inability of the heart to pump an adequate amount of blood to the
systemic circulation at normal filling pressures?
a. Pulmonary congestion
b. Congenital heart defect
c. Heart failure
d. Systemic venous congestion
ANS: C
The definition of heart failure is the inability of the heart to pump an adequate amount of
blood to the systemic circulation at normal filling pressures to meet the metabolic demands of
the body. Pulmonary congestion is an excessive accumulation of fluid in the lungs.
Congenital heart defect is a malformation of the heart present at birth. Systemic venous
congestion is an excessive accumulation of fluid in the systemic vasculature.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
7. Which term is used to describe a clinical manifestation of the systemic venous congestion that
can occur with congestive heart failure?
a. Tachypnea
b. Tachycardia
c. Peripheral edema
d. Pale, cool extremities
ANS: C
Peripheral edema, especially periorbital edema, is a clinical manifestation of systemic venous
congestion. Tachypnea is a manifestation of pulmonary congestion. Tachycardia and pale,
cool extremities are clinical manifestations of impaired myocardial function.
, PTS: 1 DIF: Cognitive Level: Analysis
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
8. What beneficial effect is achieved by administering digoxin?
a. Decreases edema
b. Decreases cardiac output
c. Increases heart size
d. Increases venous pressure
ANS: A
Digoxin has a rapid onset and is useful in increasing cardiac output, decreasing venous
pressure, and as a result decreasing edema. Heart size is decreased by digoxin.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
9. Which drug is an angiotensin-converting enzyme (ACE) inhibitor?
a. Captopril
b. Furosemide
c. Spironolactone
d. Chlorothiazide
ANS: A
Capoten is an ACE inhibitor. Lasix is a loop diuretic. Aldactone blocks the action of
aldosterone. Diuril works on the distal tubules.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
10. What is a common sign of digoxin toxicity?
a. Seizures
b. Vomiting
c. Bradypnea
d. Tachycardia
ANS: B
Vomiting is a common sign of digoxin toxicity. Seizures are not associated with digoxin
toxicity. The child will have a slower heart rate, not respiratory rate.
PTS: 1 DIF: Cognitive Level: Comprehension
6th Edition By Perry
Chapter 42: The Child With Cardiovascular Dysfunction
Perry: Maternal Child Nursing Care, 6th Edition
MULTIPLE CHOICE
1. Which complication should the nurse asses for when caring for a child post cardiac
catheterization?
a. Cardiac arrhythmia
b. Hypostatic pneumonia
c. Congestive heart failure
d. Rapidly increasing blood pressure
ANS: A
Because a catheter is introduced into the heart, a risk exists of catheter-induced arrhythmias
occurring during the procedure. These are usually transient. Hypostatic pneumonia,
congestive heart failure, and rapidly increasing blood pressure are not risks usually associated
with cardiac catheterization.
PTS: 1 DIF: Cognitive Level: Application
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
2. José is 4 year old. Preoperative teaching for a 4-year-old child scheduled for a cardiac
catheterization should be done with what primary consideration in mind?
a. Directed at his parents because he is too young to understand.
b. Detailed in regard to the actual procedures so he will know what to expect.
c. Done several days before the procedure so that he will be prepared.
d. Adapted to his level of development so that he can understand.
ANS: D
Preoperative teaching should always be directed at the child’s stage of development. The
caregivers also benefit from the same explanations. The parents may ask additional questions,
which should be answered, but the child needs to receive the information based on
developmental level. This age-group does not understand in-depth descriptions. Preschoolers
should be prepared close to the time of the cardiac catheterization.
PTS: 1 DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
,3. The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells
the nurse that her bandage is “too wet.” The nurse finds the bandage and bed soaked with blood.
What is the most appropriate initial nursing action?
a. Notify the physician.
b. Apply a new bandage with more pressure.
c. Place the child in the Trendelenburg position.
d. Apply direct pressure above the catheterization site.
ANS: D
If bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the
percutaneous skin site to localize pressure over the vessel puncture. Notifying the physician
and applying a new bandage with more pressure can be done after pressure is applied. The
nurse can have someone else notify the physician while the pressure is being maintained. The
Trendelenburg position would not be helpful; it would increase the drainage from the lower
extremities.
PTS: 1 DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
4. Which defect results in increased pulmonary blood flow?
a. Pulmonic stenosis
b. Tricuspid atresia
c. Atrial septal defect
d. Transposition of the great arteries
ANS: C
Atrial septal defect results in increased pulmonary blood flow. Blood flows from the left
atrium (higher pressure) into the right atrium (lower pressure) and then to the lungs via the
pulmonary artery. Pulmonic stenosis is an obstruction to blood flowing from the ventricles.
Tricuspid atresia results in decreased pulmonary blood flow. Transposition of the great
arteries results in mixed blood flow.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
5. Which structural defects constitute tetralogy of Fallot?
a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular
hypertrophy
b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
, d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular
hypertrophy
ANS: A
Tetralogy of Fallot has these four characteristics: pulmonary stenosis, ventricular septal
defect, overriding aorta, and right ventricular hypertrophy. There is pulmonic stenosis but not
aortic stenosis in tetralogy of Fallot. Right ventricular hypertrophy, not left ventricular
hypertrophy, is present in tetralogy of Fallot. There is a ventricular septal defect, not an atrial
septal defect, and overriding aorta, not aortic hypertrophy, is present.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
6. What is best described as the inability of the heart to pump an adequate amount of blood to the
systemic circulation at normal filling pressures?
a. Pulmonary congestion
b. Congenital heart defect
c. Heart failure
d. Systemic venous congestion
ANS: C
The definition of heart failure is the inability of the heart to pump an adequate amount of
blood to the systemic circulation at normal filling pressures to meet the metabolic demands of
the body. Pulmonary congestion is an excessive accumulation of fluid in the lungs.
Congenital heart defect is a malformation of the heart present at birth. Systemic venous
congestion is an excessive accumulation of fluid in the systemic vasculature.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
7. Which term is used to describe a clinical manifestation of the systemic venous congestion that
can occur with congestive heart failure?
a. Tachypnea
b. Tachycardia
c. Peripheral edema
d. Pale, cool extremities
ANS: C
Peripheral edema, especially periorbital edema, is a clinical manifestation of systemic venous
congestion. Tachypnea is a manifestation of pulmonary congestion. Tachycardia and pale,
cool extremities are clinical manifestations of impaired myocardial function.
, PTS: 1 DIF: Cognitive Level: Analysis
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
8. What beneficial effect is achieved by administering digoxin?
a. Decreases edema
b. Decreases cardiac output
c. Increases heart size
d. Increases venous pressure
ANS: A
Digoxin has a rapid onset and is useful in increasing cardiac output, decreasing venous
pressure, and as a result decreasing edema. Heart size is decreased by digoxin.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
9. Which drug is an angiotensin-converting enzyme (ACE) inhibitor?
a. Captopril
b. Furosemide
c. Spironolactone
d. Chlorothiazide
ANS: A
Capoten is an ACE inhibitor. Lasix is a loop diuretic. Aldactone blocks the action of
aldosterone. Diuril works on the distal tubules.
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
10. What is a common sign of digoxin toxicity?
a. Seizures
b. Vomiting
c. Bradypnea
d. Tachycardia
ANS: B
Vomiting is a common sign of digoxin toxicity. Seizures are not associated with digoxin
toxicity. The child will have a slower heart rate, not respiratory rate.
PTS: 1 DIF: Cognitive Level: Comprehension
