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 ["B","D","E"]

Explanation

A. Swelling in all extremities is not typically a symptom of VSD; it may indicate a different cardiac or renal issue.
B. Frequent lung infections are common in children with VSD due to pulmonary congestion.
C. Standard weight and growth percentile is not typical for VSD, as the child may experience failure to thrive.
D. Dyspnea occurs due to increased blood flow to the lungs and pulmonary congestion.
E. A heart murmur is a hallmark of VSD, heard due to the abnormal flow of blood through the septal defect.

A. Administering pain medication as needed B. Providing a low-sodium diet to prevent fluid overload C. Encouraging the child to ambulate as soon as possible D. Assessing vital signs every 4 hours

Correct Answer is D

Explanation

A. While pain management is important, the priority is assessing for complications that could arise after the procedure.
B. Discharge teaching is important, but the priority immediately after the procedure is monitoring for complications.
C. While hydration is important, it is not the immediate priority following VP shunt placement, where the focus should be on assessing for signs of complications.
D. Regular monitoring of vital signs is crucial to detect complications such as shunt malfunction, infection, or increased intracranial pressure.

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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

Naxlex Comprehensive Predictor Exams

The nurse is caring for a newborn with a Ventricular-Septal Defect (VSD). The nurse should recognize that the signs and symptoms of this defect are? (Select All That Apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse is caring for a child who has undergone a Ventriculoperitoneal (VP) shunt placement procedure. The nurse is aware of the need for careful prioritization of care. Which of the following actions should the nurse prioritize for this child?

Correct Answer is D

Explanation

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