A nurse is collecting data from an infant who has a large patent ductus arteriosus. Which of the following is clinical manifestations should the nurse expect?
Cyanosis with crying
Weak pulses
Chronic hypoxemia
Machine-like murmur
The Correct Answer is D
A. Cyanosis with crying: Cyanosis is less common in isolated PDA and more indicative of other congenital heart defects. PDA usually results in increased pulmonary blood flow and may not directly cause cyanosis, especially in less severe cases.
B. Weak pulses: PDA typically causes increased pulmonary blood flow and can result in bounding pulses rather than weak ones. Weak pulses are more indicative of reduced cardiac output, which is not characteristic of PDA.
C. Chronic hypoxemia: Chronic hypoxemia is less associated with PDA and more common in cyanotic heart defects where oxygenated and deoxygenated blood mix. PDA primarily affects the volume of blood flow to the lungs and may not lead to hypoxemia unless complicated by other conditions.
D. Machine-like murmur: A characteristic feature of PDA is a continuous, machine-like murmur caused by turbulent blood flow between the aorta and the pulmonary artery. This murmur is a hallmark sign of PDA and is typically heard during auscultation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Scoliosis: Scoliosis is characterized by an abnormal lateral curvature of the spine, commonly detected during routine physical exams in school-aged children and adolescents. This is the correct diagnosis for the described symptom.
B. Ankylosis: Ankylosis refers to joint stiffness or immobility due to fusion of the bones, not a lateral curvature of the spine. It is typically associated with conditions like ankylosing spondylitis and does not describe a spinal curvature.
C. Kyphosis: Kyphosis involves an abnormal forward curvature of the spine, often resulting in a hunchback appearance. It is not the same as a lateral curvature and thus does not fit the description given.
D. Lordosis: Lordosis is characterized by an exaggerated inward curve of the lower spine, commonly referred to as swayback. It does not involve lateral curvature and therefore is not relevant to the described condition.
Correct Answer is B
Explanation
A. Capillary refill less than 2 seconds: A capillary refill time of less than 2 seconds indicates good peripheral circulation, which is normal and not a cause for concern in this context. It is not the priority.
B. Tingling in the right foot Rationale: Tingling (paraesthesia) can be a sign of nerve damage or compromised circulation, which may indicate complications such as compartment syndrome. This is a priority finding because it can lead to severe consequences if not addressed promptly.
C. 2+ right pedal pulse Rationale: A 2+ pedal pulse indicates a normal pulse strength, which suggests that there is adequate blood flow to the extremity. It is not a priority compared to the potential for neurological or circulatory compromise.
D. Respiratory rate 24/min Rationale: A respiratory rate of 24/min is within the normal range for a school-age child (18-30 breaths per minute). While it is important to monitor vital signs, it is not a priority concern related to the fracture.
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