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 B

Explanation

B Kawasaki disease primarily affects medium-sized arteries, including the coronary arteries. The inflammation associated with Kawasaki disease can weaken the walls of the blood vessels, leading to the formation of aneurysms, particularly in the coronary arteries. Coronary artery aneurysms are a hallmark complication of Kawasaki disease and can increase the risk of myocardial infarction and other cardiovascular problems.

A This option describes a possible consequence of Kawasaki disease. Kawasaki disease can cause inflammation of the blood vessels, including the coronary arteries, which can lead to the formation of coronary artery aneurysms. These aneurysms can disrupt blood flow to the heart muscle, leading to ischemia and potentially heart failure.

C Mitral valve stenosis is not a typical complication of Kawasaki disease. While Kawasaki disease can affect the cardiovascular system and lead to complications such as coronary artery aneurysms, it does not typically cause mitral valve stenosis.

D Atherosclerosis is not a direct consequence of Kawasaki disease. Kawasaki disease primarily involves inflammation of the blood vessels rather than changes in lipid levels, which are more commonly associated with conditions such as hyperlipidemia or familial hypercholesterolemia.

A. Petechial and purpuric rashes are noted on the child's trunk B. Neck flexion causes adduction and flexion movements of the lower extremities C. The child is not able to extend the leg when the thigh is flexed anteriorly at the hip D. The child complains of muscle and joint pain

Correct Answer is C

Explanation

C. This is characteristic of Kernig's sign. Kernig's sign is elicited when the thigh is flexed at the hip and then attempts to extend the leg at the knee are met with resistance or pain due to inflammation of the meninges.

A. Petechial and purpuric rashes are associated with meningococcal meningitis, not specifically with Kernig's sign. These rashes result from bleeding into the skin and are a characteristic feature of meningococcal sepsis. However, they are not directly related to Kernig's sign.
B. This observation describes Brudzinski's sign, not Kernig's sign. Brudzinski's sign occurs when passive flexion of the neck causes involuntary flexion of the hips and knees due to meningeal irritation.
D. Muscle and joint pain can be symptoms of meningitis, but they are not specific to Kernig's sign. Kernig's sign specifically refers to resistance or pain experienced when attempting to extend the leg at the knee.

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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

The nurse is caring for a child with a diagnosis of Kawasaki disease. The child's parent asks the nurse, "How does Kawasaki disease affect my child's heart and blood vessels?" On what understanding is the nurse's response based?

Correct Answer is B

Explanation

The nurse notes documentation that a child with meningitis is exhibiting a positive Kernig's sign. Which observation is a characteristic of this sign?

Correct Answer is C

Explanation

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