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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?

A.

Hypothermia related to decreased metabolic state

B.

Acute pain related to the effects of a congenital heart defect

C.

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

D.

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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Related Questions

Correct Answer is {"dropdown-group-1":"C"}

Explanation

  • Coarctation of the aorta
    Explanation: This condition involves a narrowing of the aorta, typically occurring just after the left subclavian artery. It causes higher blood pressure in the arms and lower blood pressure in the legs due to the obstruction of blood flow.

  • Patent ductus arteriosus
    Explanation: This is a condition where the ductus arteriosus, a blood vessel in the fetal heart, does not close after birth. It usually causes increased blood flow to the lungs rather than a discrepancy between upper and lower body blood pressures.

  • Tetralogy of Fallot
    Explanation: This congenital heart defect consists of four heart abnormalities. While it affects blood flow and oxygen levels, it does not typically cause a significant difference in blood pressure between the arms and legs.

  • Transposition of the great arteries
    Explanation: This condition involves the aorta and pulmonary artery being switched. It leads to severe oxygenation issues but does not usually result in a notable difference in blood pressure readings between the arms and legs.

Correct Answer is C

Explanation

a) Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy: Does not describe the specific combination seen in tetralogy of Fallot.

b) Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy: Incorrect combination of defects for tetralogy of Fallot.

c) Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy: Accurately describes the four structural defects characterizing tetralogy of Fallot.

d) Aortic stenosis, ventricular septal defect, overriding aorta, left ventricular hypertrophy: Left ventricular hypertrophy is not typically part of tetralogy of Fallot.

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