A nurse has admitted a child with ventricular septal defect (VSD) to the unit. Which nursing diagnosis is appropriate for this child?

Hypothermia related to decreased metabolic state

Acute pain related to the effects of a congenital heart defect

Ineffective tissue perfusion (peripheral) related to cyanosis secondary to congenital heart defect

Impaired gas exchange related to pulmonary congestion secondary to the increased pulmonary blood flow

Answer and Explanation

The Correct Answer is C

a) Hypothermia related to decreased metabolic state: Unlikely to be directly related to VSD unless it's causing severe complications affecting metabolic function.

b) Acute pain related to the effects of a congenital heart defect: While the child might experience pain due to surgery or interventions, it's not the primary nursing diagnosis for VSD.

c) Ineffective tissue perfusion (peripheral) related to cyanosis secondary to congenital heart defect: VSD causes increased workload on the heart, leading to decreased oxygenation and potentially causing cyanosis and ineffective tissue perfusion.

d) Impaired gas exchange related to pulmonary congestion secondary to the increased pulmonary blood flow: While pulmonary congestion can occur, ineffective tissue perfusion is more directly related to cyanosis from VSD.

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Correct Answer is B

Explanation

a) Constipation: Not typically a primary symptom of cystic fibrosis.

b) Meconium ileus: Meconium ileus is a bowel obstruction that occurs shortly after birth due to abnormally thick meconium. It is a classic early sign of cystic fibrosis in newborns. Other symptoms such as failure to thrive, persistent cough, salty-tasting skin, and recurrent respiratory infections may also manifest later.

c) Rectal prolapse: Can be related to cystic fibrosis but is not as specific as other symptoms.

d) Steatorrhea stools: Frequent fatty stools are symptoms of the disease but not specific to cystic fibrosis.

A. You should always have an antihistamine like Benadryl with you at all times B. If it happens again I will teach you what to do C. I will teach how to use an epi-pen D. You can start a desensitization process to take the allergy away

Correct Answer is C

Explanation

a) Having antihistamines like Benadryl is beneficial, but in severe allergic reactions (anaphylaxis), an epinephrine auto-injector (epi-pen) is the first-line treatment and can be life-saving.

b) Waiting for the next occurrence without preparation is risky. Immediate action is crucial in severe allergic reactions.

c) Teaching how to use an epi-pen is crucial for managing severe allergic reactions. It provides rapid relief by counteracting anaphylaxis until emergency help arrives.

d) Desensitization processes are not immediate solutions and are typically conducted under medical supervision.

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A nurse has admitted a child with ventricular septal defect (VSD) to the unit. Which nursing diagnosis is appropriate for this child?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

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