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 B
Explanation
A. Gently reinsert the tubes. Tympanostomy tubes should not be reinserted by the parent. Inserting the tubes requires medical expertise and should be performed by a healthcare professional to avoid damaging the ear.
B. Call the health care clinic to report that the tubes have fallen out. This is the correct action. The healthcare provider needs to be informed to assess if new tubes are necessary. Tubes may naturally fall out as part of the healing process, but professional evaluation is essential to determine the next steps.
C. Reassure the mother that the tubes will not fall out. It is incorrect to reassure the parent that the tubes will not fall out. Tubes can fall out naturally as the eardrum heals, and parents should be prepared for this possibility and know the appropriate steps to take.
D. Take the child to an emergency department. This is generally not necessary unless there are signs of complications such as severe pain, infection, or significant hearing loss. Routine follow-up at the clinic is sufficient for a non-emergency situation like a tube falling out.
Correct Answer is A
Explanation
A. Defining a sense of self: Adolescence is characterized by the search for identity and defining a sense of self. Erikson identifies this stage as "Identity vs. Role Confusion," where individuals explore and form their own identity separate from their family and childhood roles.
B. Learning to perform tasks independently: This is more typical of early childhood (Erikson's "Autonomy vs. Shame and Doubt"). During this stage, children are learning basic independence, such as dressing and feeding themselves.
C. Learning to use creative energies: This task is more relevant to the preschool age group (Erikson's "Initiative vs. Guilt"), where children engage in imaginative play and begin exploring their own ideas and creativity.
D. Building a sense of trust: Building a sense of trust is the primary task in infancy (Erikson's "Trust vs. Mistrust"), where infants develop trust in their caregivers and the world around them.
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