The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, "Why do my child's fingertips look like that?" On what understanding does the nurse base a response?

Clubbing occurs as a result of decreased cardiac output.

Clubbing occurs as a result of a left-to-right shunting of blood.

Clubbing occurs as a result of chronic hypoxia

Clubbing occurs as a result of untreated congestive heart failure.

Answer and Explanation

The Correct Answer is C

C. Clubbing, characterized by bulbous enlargement of the fingertips and nail bed, is a result of chronic hypoxia in tetralogy of Fallot. In tetralogy of Fallot, there is a right-to-left shunting of blood due to the presence of a ventricular septal defect, overriding aorta, pulmonary stenosis, and right ventricular hypertrophy. This leads to reduced oxygenation of blood and chronic hypoxia, which can result in clubbing of the fingertips over time.

A This option is not the primary explanation for clubbing in tetralogy of Fallot. While decreased cardiac output may contribute to some manifestations of the condition, clubbing specifically results from chronic hypoxia rather than decreased cardiac output alone.

B Clubbing is not directly caused by a left-to-right shunting of blood. Instead, it is associated with chronic hypoxia, which can occur due to right-to-left shunting of blood in tetralogy of Fallot.

D Congestive heart failure may occur in individuals with tetralogy of Fallot but it is not the primary cause of clubbing. Clubbing in tetralogy of Fallot is primarily attributed to chronic hypoxia rather than heart failure alone.

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Correct Answer is A

Explanation

A. Rheumatic fever often develops as a complication of untreated or inadequately treated streptococcal throat infections, particularly group A Streptococcus. A history of a recent sore throat in a family member could suggest a streptococcal infection, which is a risk factor for developing rheumatic fever.

B. Chickenpox is caused by the varicella-zoster virus and is not directly related to rheumatic fever. While viral infections can trigger or exacerbate rheumatic fever in susceptible individuals, chickenpox itself is not a significant risk factor for rheumatic fever.

C. Fifth disease, also known as erythema infectiosum, is caused by parvovirus B19 and is not associated with rheumatic fever. Fifth disease primarily affects the skin, causing a characteristic rash, and is typically a mild illness in children.

D. Gastritis, inflammation of the stomach lining, is not directly related to rheumatic fever. While some gastrointestinal conditions may be associated with autoimmune disorders, gastritis itself is not a known risk factor for rheumatic fever.

A. Improve muscle control and coordination. B. Eliminate the cause of the disease. C. Prevent the occurrence of emotional disturbances. D. Maximize the child's assets and minimize the limitations.

Correct Answer is D

Explanation

D. The aim is to focus on the child's strengths and abilities while addressing limitations and challenges associated with the condition. This approach emphasizes maximizing the child's potential for development, independence, and participation in daily activities, education, and social interactions, while also providing support and resources to address any limitations or barriers they may encounter.

A. Another goal of treatment and care is to maximize the child's functional abilities by improving muscle control, coordination, and mobility through various therapies, such as physical therapy, occupational therapy, and speech therapy. However, this is not the primary goal.

B. Cerebral palsy is a neurological condition caused by damage to the developing brain, often occurring before birth. While efforts to prevent cerebral palsy are important, once the condition has developed, the focus shifts to managing symptoms and optimizing the child's functioning rather than eliminating the cause.

C. Emotional well-being is an important aspect of overall health for children with cerebral palsy but it is not typically the primary goal of care. Emotional disturbances may occur in some children with cerebral palsy due to various factors such as coping with the challenges of the condition, social interactions, or other comorbidities, but the primary focus of the care plan is usually on addressing physical and functional impairments.

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The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, "Why do my child's fingertips look like that?" On what understanding does the nurse base a response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has rheumatic fever. When obtaining the client's medical history from the parent, the nurse should recognize which of the following findings as significant?

Correct Answer is A

Explanation

Which is the primary goal that would be included in the plan of care for a child who has cerebral palsy?

Correct Answer is D

Explanation

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