Test bank principles of pediatric nursing 8th edition
Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 6th Edition Cognitive Level: Analyzing
Client Need: Physiological Integrity
Chapter 21 - Cardiac Client Need Sub: Physiological Adaptation
Question 1 Nursing/Integrated Concepts: Nursing Process: Assessment
Type: MCSA Learning Outcome: LO 21.2 Describe the pathophysiology associated with
congenital heart defects with increased pulmonary circulation, decreased
The nurse has admitted a child with tricuspid atresia. The nurse would expect which pulmonary circulation, mixed defects, and obstructed systemic blood flow.
initial lab result? Question 2
Type: MCSA
1. A high hemoglobin
2. A low hematocrit A child has been admitted to the hospital unit in congestive heart failure (CHF).
3. A high white blood cell count Which symptom would the nurse anticipate upon assessment of the child?
4. A low platelet count
Correct Answer: 1 1. Weight loss
Rationale 1: The childs bone marrow responds to chronic hypoxemia by producing 2. Bradycardia
more red blood cells to increase the amount of hemoglobin available to carry 3. Tachycardia
oxygen to the tissues. This occurs in cases of cyanotic heart defects such as tricuspid 4. Increased blood pressure
atresia. Therefore, the hematocrit would not be low, the white blood cell count Correct Answer: 3
would not be high (unless an infection were present), and the platelets would be Rationale 1: Tachycardia is a sign of congestive heart failure because the heart
normal. attempts to improve cardiac output by beating faster. Bradycardia is a serious sign
Rationale 2: The childs bone marrow responds to chronic hypoxemia by producing and can indicate impending cardiac arrest. Blood pressure does not increase in CHF,
more red blood cells to increase the amount of hemoglobin available to carry and the weight, instead of decreasing, increases because of retention of fluids.
oxygen to the tissues. This occurs in cases of cyanotic heart defects such as tricuspid Rationale 2: Tachycardia is a sign of congestive heart failure because the heart
atresia. Therefore, the hematocrit would not be low, the white blood cell count attempts to improve cardiac output by beating faster. Bradycardia is a serious sign
would not be high (unless an infection were present), and the platelets would be and can indicate impending cardiac arrest. Blood pressure does not increase in CHF,
normal. and the weight, instead of decreasing, increases because of retention of fluids.
Rationale 3: The childs bone marrow responds to chronic hypoxemia by producing Rationale 3: Tachycardia is a sign of congestive heart failure because the heart
more red blood cells to increase the amount of hemoglobin available to carry attempts to improve cardiac output by beating faster. Bradycardia is a serious sign
oxygen to the tissues. This occurs in cases of cyanotic heart defects such as tricuspid and can indicate impending cardiac arrest. Blood pressure does not increase in CHF,
atresia. Therefore, the hematocrit would not be low, the white blood cell count and the weight, instead of decreasing, increases because of retention of fluids.
would not be high (unless an infection were present), and the platelets would be Rationale 4: Tachycardia is a sign of congestive heart failure because the heart
normal. attempts to improve cardiac output by beating faster. Bradycardia is a serious sign
Rationale 4: The childs bone marrow responds to chronic hypoxemia by producing and can indicate impending cardiac arrest. Blood pressure does not increase in CHF,
more red blood cells to increase the amount of hemoglobin available to carry and the weight, instead of decreasing, increases because of retention of fluids.
oxygen to the tissues. This occurs in cases of cyanotic heart defects such as tricuspid Global Rationale: Tachycardia is a sign of congestive heart failure because the heart
atresia. Therefore, the hematocrit would not be low, the white blood cell count attempts to improve cardiac output by beating faster. Bradycardia is a serious sign
would not be high (unless an infection were present), and the platelets would be and can indicate impending cardiac arrest. Blood pressure does not increase in CHF,
normal. and the weight, instead of decreasing, increases because of retention of fluids.
Global Rationale: The childs bone marrow responds to chronic hypoxemia by Cognitive Level: Analyzing
producing more red blood cells to increase the amount of hemoglobin available to Client Need: Physiological Integrity
carry oxygen to the tissues. This occurs in cases of cyanotic heart defects such as Client Need Sub: Physiological Adaptation
tricuspid atresia. Therefore, the hematocrit would not be low, the white blood cell Nursing/Integrated Concepts: Nursing Process: Assessment
count would not be high (unless an infection were present), and the platelets would Learning Outcome: LO 21.6 Develop a nursing care plan for a child with congestive
be normal. heart failure.
, Question 3 Rationale 1: The nurse checks the extremity to determine adequacy of circulation
Type: MCSA following a cardiac catheterization. An extremity that is warm with capillary refill of
less than three seconds has adequate circulation. Other indicators of adequate
A toddler is started on digoxin (Lanoxin) for cardiac failure. Which is the initial circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate
symptom the nurse would assess if the child develops digoxin (Lanoxin) toxicity? sensation, and pinkness of skin color. If the capillary refill is over three seconds; if
any of the pedal pulses are absent and/or weakened; or if the extremity is cool,
1. Lowered blood pressure
cyanotic, or lacking sensation, circulation may not be adequate.
2. Tinnitus
Rationale 2: The nurse checks the extremity to determine adequacy of circulation
3. Ataxia
following a cardiac catheterization. An extremity that is warm with capillary refill of
4. A change in heart rhythm
less than three seconds has adequate circulation. Other indicators of adequate
Correct Answer: 4
circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate
Rationale 1: An early sign of digoxin (Lanoxin) toxicity is a change in heart rhythm.
sensation, and pinkness of skin color. If the capillary refill is over three seconds; if
Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in
any of the pedal pulses are absent and/or weakened; or if the extremity is cool,
the ears), or ataxia (unsteady gait).
cyanotic, or lacking sensation, circulation may not be adequate.
Rationale 2: An early sign of digoxin (Lanoxin) toxicity is a change in heart rhythm.
Rationale 3: The nurse checks the extremity to determine adequacy of circulation
Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in
following a cardiac catheterization. An extremity that is warm with capillary refill of
the ears), or ataxia (unsteady gait).
less than three seconds has adequate circulation. Other indicators of adequate
Rationale 3: An early sign of digoxin (Lanoxin) toxicity is a change in heart rhythm.
circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate
Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in
sensation, and pinkness of skin color. If the capillary refill is over three seconds; if
the ears), or ataxia (unsteady gait).
any of the pedal pulses are absent and/or weakened; or if the extremity is cool,
Rationale 4: An early sign of digoxin (Lanoxin) toxicity is a change in heart rhythm.
cyanotic, or lacking sensation, circulation may not be adequate.
Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in
Rationale 4: The nurse checks the extremity to determine adequacy of circulation
the ears), or ataxia (unsteady gait).
following a cardiac catheterization. An extremity that is warm with capillary refill of
Global Rationale: An early sign of digoxin (Lanoxin) toxicity is a change in heart
less than three seconds has adequate circulation. Other indicators of adequate
rhythm. Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus
circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate
(ringing in the ears), or ataxia (unsteady gait).
sensation, and pinkness of skin color. If the capillary refill is over three seconds; if
Cognitive Level: Analyzing
any of the pedal pulses are absent and/or weakened; or if the extremity is cool,
Client Need: Physiological Integrity
cyanotic, or lacking sensation, circulation may not be adequate.
Client Need Sub: Physiological Adaptation
Global Rationale: The nurse checks the extremity to determine adequacy of
Nursing/Integrated Concepts: Nursing Process: Assessment
circulation following a cardiac catheterization. An extremity that is warm with
Learning Outcome: LO 21.5 Recognize the signs and symptoms of congestive heart
capillary refill of less than three seconds has adequate circulation. Other indicators
failure in an infant and child.
of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses,
Question 4
adequate sensation, and pinkness of skin color. If the capillary refill is over three
Type: MCSA
seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity
The nurse is checking peripheral perfusion to a childs extremity following a cardiac is cool, cyanotic, or lacking sensation, circulation may not be adequate.
catheterization. Which assessment finding indicates adequate peripheral circulation Cognitive Level: Analyzing
to the affected extremity? Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
1. A capillary refill of greater than three seconds Nursing/Integrated Concepts: Nursing Process: Assessment
2. A palpable dorsalis pedis pulse but a weak posterior tibial pulse Learning Outcome: LO 21.1 Describe the anatomy and physiology of the
3. A decrease in sensation with a weakened dorsalis pedis pulse cardiovascular system, focusing on the flow of blood and the action of heart valves.
4. A capillary refill of less than three seconds with palpable warmth Question 5
Correct Answer: 4 Type: MCSA
Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 6th Edition Cognitive Level: Analyzing
Client Need: Physiological Integrity
Chapter 21 - Cardiac Client Need Sub: Physiological Adaptation
Question 1 Nursing/Integrated Concepts: Nursing Process: Assessment
Type: MCSA Learning Outcome: LO 21.2 Describe the pathophysiology associated with
congenital heart defects with increased pulmonary circulation, decreased
The nurse has admitted a child with tricuspid atresia. The nurse would expect which pulmonary circulation, mixed defects, and obstructed systemic blood flow.
initial lab result? Question 2
Type: MCSA
1. A high hemoglobin
2. A low hematocrit A child has been admitted to the hospital unit in congestive heart failure (CHF).
3. A high white blood cell count Which symptom would the nurse anticipate upon assessment of the child?
4. A low platelet count
Correct Answer: 1 1. Weight loss
Rationale 1: The childs bone marrow responds to chronic hypoxemia by producing 2. Bradycardia
more red blood cells to increase the amount of hemoglobin available to carry 3. Tachycardia
oxygen to the tissues. This occurs in cases of cyanotic heart defects such as tricuspid 4. Increased blood pressure
atresia. Therefore, the hematocrit would not be low, the white blood cell count Correct Answer: 3
would not be high (unless an infection were present), and the platelets would be Rationale 1: Tachycardia is a sign of congestive heart failure because the heart
normal. attempts to improve cardiac output by beating faster. Bradycardia is a serious sign
Rationale 2: The childs bone marrow responds to chronic hypoxemia by producing and can indicate impending cardiac arrest. Blood pressure does not increase in CHF,
more red blood cells to increase the amount of hemoglobin available to carry and the weight, instead of decreasing, increases because of retention of fluids.
oxygen to the tissues. This occurs in cases of cyanotic heart defects such as tricuspid Rationale 2: Tachycardia is a sign of congestive heart failure because the heart
atresia. Therefore, the hematocrit would not be low, the white blood cell count attempts to improve cardiac output by beating faster. Bradycardia is a serious sign
would not be high (unless an infection were present), and the platelets would be and can indicate impending cardiac arrest. Blood pressure does not increase in CHF,
normal. and the weight, instead of decreasing, increases because of retention of fluids.
Rationale 3: The childs bone marrow responds to chronic hypoxemia by producing Rationale 3: Tachycardia is a sign of congestive heart failure because the heart
more red blood cells to increase the amount of hemoglobin available to carry attempts to improve cardiac output by beating faster. Bradycardia is a serious sign
oxygen to the tissues. This occurs in cases of cyanotic heart defects such as tricuspid and can indicate impending cardiac arrest. Blood pressure does not increase in CHF,
atresia. Therefore, the hematocrit would not be low, the white blood cell count and the weight, instead of decreasing, increases because of retention of fluids.
would not be high (unless an infection were present), and the platelets would be Rationale 4: Tachycardia is a sign of congestive heart failure because the heart
normal. attempts to improve cardiac output by beating faster. Bradycardia is a serious sign
Rationale 4: The childs bone marrow responds to chronic hypoxemia by producing and can indicate impending cardiac arrest. Blood pressure does not increase in CHF,
more red blood cells to increase the amount of hemoglobin available to carry and the weight, instead of decreasing, increases because of retention of fluids.
oxygen to the tissues. This occurs in cases of cyanotic heart defects such as tricuspid Global Rationale: Tachycardia is a sign of congestive heart failure because the heart
atresia. Therefore, the hematocrit would not be low, the white blood cell count attempts to improve cardiac output by beating faster. Bradycardia is a serious sign
would not be high (unless an infection were present), and the platelets would be and can indicate impending cardiac arrest. Blood pressure does not increase in CHF,
normal. and the weight, instead of decreasing, increases because of retention of fluids.
Global Rationale: The childs bone marrow responds to chronic hypoxemia by Cognitive Level: Analyzing
producing more red blood cells to increase the amount of hemoglobin available to Client Need: Physiological Integrity
carry oxygen to the tissues. This occurs in cases of cyanotic heart defects such as Client Need Sub: Physiological Adaptation
tricuspid atresia. Therefore, the hematocrit would not be low, the white blood cell Nursing/Integrated Concepts: Nursing Process: Assessment
count would not be high (unless an infection were present), and the platelets would Learning Outcome: LO 21.6 Develop a nursing care plan for a child with congestive
be normal. heart failure.
, Question 3 Rationale 1: The nurse checks the extremity to determine adequacy of circulation
Type: MCSA following a cardiac catheterization. An extremity that is warm with capillary refill of
less than three seconds has adequate circulation. Other indicators of adequate
A toddler is started on digoxin (Lanoxin) for cardiac failure. Which is the initial circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate
symptom the nurse would assess if the child develops digoxin (Lanoxin) toxicity? sensation, and pinkness of skin color. If the capillary refill is over three seconds; if
any of the pedal pulses are absent and/or weakened; or if the extremity is cool,
1. Lowered blood pressure
cyanotic, or lacking sensation, circulation may not be adequate.
2. Tinnitus
Rationale 2: The nurse checks the extremity to determine adequacy of circulation
3. Ataxia
following a cardiac catheterization. An extremity that is warm with capillary refill of
4. A change in heart rhythm
less than three seconds has adequate circulation. Other indicators of adequate
Correct Answer: 4
circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate
Rationale 1: An early sign of digoxin (Lanoxin) toxicity is a change in heart rhythm.
sensation, and pinkness of skin color. If the capillary refill is over three seconds; if
Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in
any of the pedal pulses are absent and/or weakened; or if the extremity is cool,
the ears), or ataxia (unsteady gait).
cyanotic, or lacking sensation, circulation may not be adequate.
Rationale 2: An early sign of digoxin (Lanoxin) toxicity is a change in heart rhythm.
Rationale 3: The nurse checks the extremity to determine adequacy of circulation
Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in
following a cardiac catheterization. An extremity that is warm with capillary refill of
the ears), or ataxia (unsteady gait).
less than three seconds has adequate circulation. Other indicators of adequate
Rationale 3: An early sign of digoxin (Lanoxin) toxicity is a change in heart rhythm.
circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate
Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in
sensation, and pinkness of skin color. If the capillary refill is over three seconds; if
the ears), or ataxia (unsteady gait).
any of the pedal pulses are absent and/or weakened; or if the extremity is cool,
Rationale 4: An early sign of digoxin (Lanoxin) toxicity is a change in heart rhythm.
cyanotic, or lacking sensation, circulation may not be adequate.
Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus (ringing in
Rationale 4: The nurse checks the extremity to determine adequacy of circulation
the ears), or ataxia (unsteady gait).
following a cardiac catheterization. An extremity that is warm with capillary refill of
Global Rationale: An early sign of digoxin (Lanoxin) toxicity is a change in heart
less than three seconds has adequate circulation. Other indicators of adequate
rhythm. Digoxin (Lanoxin) toxicity does not cause lowered blood pressure, tinnitus
circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate
(ringing in the ears), or ataxia (unsteady gait).
sensation, and pinkness of skin color. If the capillary refill is over three seconds; if
Cognitive Level: Analyzing
any of the pedal pulses are absent and/or weakened; or if the extremity is cool,
Client Need: Physiological Integrity
cyanotic, or lacking sensation, circulation may not be adequate.
Client Need Sub: Physiological Adaptation
Global Rationale: The nurse checks the extremity to determine adequacy of
Nursing/Integrated Concepts: Nursing Process: Assessment
circulation following a cardiac catheterization. An extremity that is warm with
Learning Outcome: LO 21.5 Recognize the signs and symptoms of congestive heart
capillary refill of less than three seconds has adequate circulation. Other indicators
failure in an infant and child.
of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses,
Question 4
adequate sensation, and pinkness of skin color. If the capillary refill is over three
Type: MCSA
seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity
The nurse is checking peripheral perfusion to a childs extremity following a cardiac is cool, cyanotic, or lacking sensation, circulation may not be adequate.
catheterization. Which assessment finding indicates adequate peripheral circulation Cognitive Level: Analyzing
to the affected extremity? Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
1. A capillary refill of greater than three seconds Nursing/Integrated Concepts: Nursing Process: Assessment
2. A palpable dorsalis pedis pulse but a weak posterior tibial pulse Learning Outcome: LO 21.1 Describe the anatomy and physiology of the
3. A decrease in sensation with a weakened dorsalis pedis pulse cardiovascular system, focusing on the flow of blood and the action of heart valves.
4. A capillary refill of less than three seconds with palpable warmth Question 5
Correct Answer: 4 Type: MCSA
