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. Kawasaki disease is a systemic vasculitis that predominantly affects medium-sized arteries, including the coronary arteries of the heart. The inflammation of the blood vessels can lead to coronary artery aneurysms and other cardiovascular complications if not promptly treated.

B. The respiratory system is not primarily affected by Kawasaki disease. While Kawasaki disease is a systemic illness that can cause fever and inflammation, it primarily affects the cardiovascular system, with inflammation of blood vessels, particularly the coronary arteries.

C. The integumentary system (skin, hair, nails) is not primarily affected by Kawasaki disease. Although some children with Kawasaki disease may develop a rash, particularly in the acute phase of the illness, skin involvement is not the primary feature of the disease.

D. Gastrointestinal symptoms, such as abdominal pain, vomiting, or diarrhea, can occur in Kawasaki disease but they are not the primary focus of the disease. Kawasaki disease primarily affects the cardiovascular system, leading to inflammation of blood vessels and potential complications such as coronary artery aneurysms.

A. A private room with contact/droplet precautions B. A semi-private room with an infant who has croup C. A private room with protective isolation D. A semi-private room with a toddler who has pneumonia

Correct Answer is A

Explanation

A. This option is the most appropriate choice for an infant with respiratory syncytial virus (RSV). RSV is highly contagious and primarily spreads through respiratory secretions. Placing the infant in a private room helps to minimize the risk of transmission to other patients. Contact and droplet precautions should be implemented to further prevent the spread of the virus.

B. This choice is not ideal because both RSV and croup are respiratory infections that can spread easily among infants. Placing an infant with RSV in a semi-private room with another infant increases the risk of transmission of both infections to each other.

C. While isolating the infant in a private room is appropriate for preventing the spread of RSV, the term "protective isolation" typically refers to a type of isolation used for patients who have compromised immune systems.

D. Placing the infant with RSV in a semi-private room with a toddler who has pneumonia is not recommended. Both RSV and pneumonia are respiratory infections that can spread easily among patients, especially infants and young children who are more susceptible to complications.

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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 Kawasaki disease. Which of the following systems is primarily affected by this disease?

Correct Answer is A

Explanation

A nurse is assisting with the admission of an infant who has respiratory syncytial virus (RSV). Which of the following rooms should the nurse assign the infant?

Correct Answer is A

Explanation

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