PassPoint: Extra Alternate-Format
Which findings would support cardiac tamponade?
Bradycardia
Hypertension
Restlessness
Muffled heart sounds
Widened pulse pressure
Distended neck veins - ANS-Restlessness
Muffled heart sounds
Distended neck veins
Cardiac tamponade is a life-threatening condition caused by the accumulation of fluid in
the pericardium. This fluid, which can be blood, pus, or air, compresses the heart and
restricts blood flow to the ventricles. Symptoms of cardiac tamponade include elevated
venous pressure, distended neck veins, Kussmaul's sign, hypotension and narrowed
pulse pressure, tachycardia, dyspnea, restlessness, and anxiety, cyanosis of the lips
and nails, diaphoresis, muffled heart sounds, pulsus paradoxus, decreased friction rub,
decreased QRS voltage, and electrical alternans.
The nurse is evaluating an external fetal monitoring strip of a client in labor. What
condition is the nurse concerned about?
Cephalopelvic disproportion
Oligohydramnios
Uteroplacental insufficiency
Hydramnios - ANS-Uteroplacental insufficiency
This fetal monitoring strip illustrates a late deceleration. The decrease in fetal heart rate
begins after the peak of the contraction and doesn't return to baseline until the
contraction is over. Late decelerations are associated with uteroplacental insufficiency,
shock, or fetal metabolic acidosis. Cephalopelvic disproportion may cause early, not
late, decelerations early in labor. Oligohydramnios be associated with variable
decelerations. Hydramnios may be associated with uterine rupture.
The nurse is caring for a child with tricuspid atresia who develops polycythemia. Which
statements most accurately describe this manifestation? - ANS-Polycythemia is an
, increased number of red blood cells, thereby increasing the ability of the blood to carry
oxygen to the cells. It is the body's attempt at compensating for the chronic hypoxia
associated with this heart defect. Due to this clinical manifestation, the viscosity of the
blood increases, which leaves the child at risk for developing a thrombus, particularly
when dehydrated. There is also not as much room for clotting factors, which can leave
the child at risk for blood clotting disorders.
A client is admitted with hemophilia A. Which sports should the nurse recommend as
safe for the client to participate? Select all that apply. - ANS-Swimming
Golf
Hemophilia A or classic hemophilia is a bleeding disorder that results from a deficiency
or abnormality of clotting factor VIII. A client with hemophilia should avoid contact sports
like soccer, baseball, and basketball because of the risk of bleeding with injury. The
client can safely participate in noncontact sports such as swimming and golf.
The parents of an infant recently diagnosed with tricuspid atresia have been told that
their child will need a series of surgeries, in three stages, during the first few years of
life. Which statements indicate that the parents have an understanding of the
procedures? Select all that apply.
"My child will have this dusky color for the rest of his life." "These procedures will make
my child have a normal heart." "Once fixed, my baby will not have to take any more
medicine." "My baby will be just like all of the other children once the surgeries are all
done." "My child will have to be closely monitored for signs of a stroke. - ANS-"My child
will have this dusky color for the rest of his life."
"My child will have to be closely monitored for signs of a stroke."
The child will be dusky, particularly around mucous membranes and nail beds, for the
rest of his life as a result of chronic hypoxemia. The resultant polycythemia and
increased blood viscosity increase the child's chances of developing a thrombus,
leading to a cerebrovascular accident or stroke. The three surgeries do give the child a
"normal" heart, as they do not fix the original defect. The child will more than likely be on
medications for the rest of his life, and will likely be smaller in stature than other
children.
A client is diagnosed with postpartum preeclampsia and asks the nurse what could have
caused this to occur. Which causative factors should the nurse include in her teaching?
Select all that apply.
Which findings would support cardiac tamponade?
Bradycardia
Hypertension
Restlessness
Muffled heart sounds
Widened pulse pressure
Distended neck veins - ANS-Restlessness
Muffled heart sounds
Distended neck veins
Cardiac tamponade is a life-threatening condition caused by the accumulation of fluid in
the pericardium. This fluid, which can be blood, pus, or air, compresses the heart and
restricts blood flow to the ventricles. Symptoms of cardiac tamponade include elevated
venous pressure, distended neck veins, Kussmaul's sign, hypotension and narrowed
pulse pressure, tachycardia, dyspnea, restlessness, and anxiety, cyanosis of the lips
and nails, diaphoresis, muffled heart sounds, pulsus paradoxus, decreased friction rub,
decreased QRS voltage, and electrical alternans.
The nurse is evaluating an external fetal monitoring strip of a client in labor. What
condition is the nurse concerned about?
Cephalopelvic disproportion
Oligohydramnios
Uteroplacental insufficiency
Hydramnios - ANS-Uteroplacental insufficiency
This fetal monitoring strip illustrates a late deceleration. The decrease in fetal heart rate
begins after the peak of the contraction and doesn't return to baseline until the
contraction is over. Late decelerations are associated with uteroplacental insufficiency,
shock, or fetal metabolic acidosis. Cephalopelvic disproportion may cause early, not
late, decelerations early in labor. Oligohydramnios be associated with variable
decelerations. Hydramnios may be associated with uterine rupture.
The nurse is caring for a child with tricuspid atresia who develops polycythemia. Which
statements most accurately describe this manifestation? - ANS-Polycythemia is an
, increased number of red blood cells, thereby increasing the ability of the blood to carry
oxygen to the cells. It is the body's attempt at compensating for the chronic hypoxia
associated with this heart defect. Due to this clinical manifestation, the viscosity of the
blood increases, which leaves the child at risk for developing a thrombus, particularly
when dehydrated. There is also not as much room for clotting factors, which can leave
the child at risk for blood clotting disorders.
A client is admitted with hemophilia A. Which sports should the nurse recommend as
safe for the client to participate? Select all that apply. - ANS-Swimming
Golf
Hemophilia A or classic hemophilia is a bleeding disorder that results from a deficiency
or abnormality of clotting factor VIII. A client with hemophilia should avoid contact sports
like soccer, baseball, and basketball because of the risk of bleeding with injury. The
client can safely participate in noncontact sports such as swimming and golf.
The parents of an infant recently diagnosed with tricuspid atresia have been told that
their child will need a series of surgeries, in three stages, during the first few years of
life. Which statements indicate that the parents have an understanding of the
procedures? Select all that apply.
"My child will have this dusky color for the rest of his life." "These procedures will make
my child have a normal heart." "Once fixed, my baby will not have to take any more
medicine." "My baby will be just like all of the other children once the surgeries are all
done." "My child will have to be closely monitored for signs of a stroke. - ANS-"My child
will have this dusky color for the rest of his life."
"My child will have to be closely monitored for signs of a stroke."
The child will be dusky, particularly around mucous membranes and nail beds, for the
rest of his life as a result of chronic hypoxemia. The resultant polycythemia and
increased blood viscosity increase the child's chances of developing a thrombus,
leading to a cerebrovascular accident or stroke. The three surgeries do give the child a
"normal" heart, as they do not fix the original defect. The child will more than likely be on
medications for the rest of his life, and will likely be smaller in stature than other
children.
A client is diagnosed with postpartum preeclampsia and asks the nurse what could have
caused this to occur. Which causative factors should the nurse include in her teaching?
Select all that apply.
