A nurse is caring for a preschool client who has Tetralogy of Fallot (TOF). What are the defects the nurse should be aware of when caring for a client with Teratology of Fallot (TOF)? (Select all that apply).

Pyloric Stenosis.

Left Ventricular Hypertrophy. (LVH)

Thickened Right Ventricular Wall

Overriding Aorta.

Ventricular Septal Defect. (MSD)

Pulmonary Stenosis.

Answer and Explanation

Correct Answer : C,D,E,F

A.   Pyloric stenosis is unrelated to TOF. It involves the narrowing of the pyloric valve in the stomach and is not a defect associated with TOF.
B.   LVH is not typically a feature of TOF, as the primary issues affect the right ventricle.
C.   Right ventricular hypertrophy occurs due to the obstruction of blood flow through the pulmonary valve in TOF.
D.   In TOF, the aorta is positioned directly over the ventricular septal defect (VSD), which is known as overriding aorta.
E.   A VSD is a key component of TOF, where there is a hole between the ventricles, allowing oxygen-poor and oxygen-rich blood to mix.
F.   Pulmonary stenosis (narrowing of the pulmonary valve) is one of the hallmark defects in TOF.

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Correct Answer is A

Explanation

A. The nurse should avoid manipulating the stent or dressings to prevent dislodging or introducing infection.
B. Tub baths should be avoided until healing occurs, typically after the wound has been sufficiently healed.
C. Fluid restriction is not necessary unless prescribed for another condition.
D. Anticholinergic medications are not indicated unless there is a specific need, such as managing bladder spasms.

A. Oliguria B. Negative Kernig's sign C. Bulging fontanel D. Negative Brudzinski sign

Correct Answer is C

Explanation

A. Oliguria (decreased urine output) may be a sign of dehydration or kidney dysfunction but is not typically the primary symptom of a CNS infection.
B. A negative Kernig's sign (no resistance to leg extension) is a reassuring sign and suggests that meningitis or other CNS infections are less likely. A positive sign would suggest possible meningitis.
C. Bulging of the fontanel is a sign of increased intracranial pressure, which can occur in CNS infections such as meningitis. This is a critical finding that requires immediate attention.
D. A negative Brudzinski sign means there is no neck stiffness or pain when the neck is flexed, which is a good finding. A positive sign would suggest the presence of meningitis.

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A nurse is caring for a preschool client who has Tetralogy of Fallot (TOF). What are the defects the nurse should be aware of when caring for a client with Teratology of Fallot (TOF)? (Select all that apply).

Nursing Test Bank

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