Chapter 26 Child Health Nursing Partnering With Children & Families, 3rd Edition

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

Chapter 26

Question 1

Type: MCSA

The nurse is checking peripheral perfusion to a child’s extremity following a cardiac catheterization. If there is adequate peripheral circulation, the nurse would find that the extremity:

1. Has a capillary refill of greater than three seconds.
2. Is warm, with a capillary refill of less than three seconds.
3. Has decreased sensation with a weakened dorsalis pedis pulse.
4. Has a palpable dorsalis pedis pulse but a weak posterior tibial pulse.

Correct Answer: 2

Rationale 1: 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, cyanotic, or lacking sensation, circulation might not be adequate.

Rationale 2: The nurse checks the extremity to determine adequacy of circulation following a cardiac catheterization. An extremity that is warm with capillary refill of less than three seconds has adequate circulation. Other indicators of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate sensation, and pinkness of skin color.

Rationale 3: 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, cyanotic, or lacking sensation, circulation might not be adequate.

Rationale 4: 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, cyanotic, or lacking sensation, circulation might not be adequate.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-3

Question 2

Type: MCSA

The nurse has admitted a child with a cyanotic heart defect. Which initial lab result will the nurse anticipate?

1. A low platelet count
2. A high white blood cell count
3. A high hemoglobin
4. A low hematocrit

Correct Answer: 3

Rationale 1: The platelets would be normal.

Rationale 2: The white blood cell count would not be high unless an infection was present.

Rationale 3: The child’s bone marrow responds to chronic hypoxemia by producing more red blood cells to increase the amount of hemoglobin available to carry oxygen to the tissues. This occurs in cases of cyanotic heart defects.

Rationale 4: The hematocrit would not be low.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-3

Question 3

Type: MCSA

The nurse has admitted a child with a ventricular septal defect (VSD) to the unit. Which nursing diagnosis is appropriate for this child?

1. Hypothermia related to decreased metabolic state
2. Acute pain related to the effects of a congenital heart defect
3. Ineffective tissue perfusion (peripheral) related to cyanosis secondary to congenital heart defect
4. Impaired gas exchange related to pulmonary congestion secondary to the increased pulmonary blood flow

Correct Answer: 4

Rationale 1: Ventricular septal defects do not cause pain, fever, or deficient fluid volume.

Rationale 2: Ventricular septal defects do not cause pain, fever, or deficient fluid volume.

Rationale 3: VSDs are left to right shunts, which increases pulmonary blood flow without cyanosis.

Rationale 4: Because of the increased pulmonary congestion, impaired gas exchange would be an appropriate nursing diagnosis.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 26-3

Question 4

Type: MCSA

The nurse finds that an infant has stronger pulses in the upper extremities than in the lower extremities and higher blood pressure readings in the arms than in the legs. This could be indicative of what heart defect?

1. Transposition of the great vessels
2. Patent ductus arteriosus
3. Coarctation of the aorta
4. Atrial septal defect

Correct Answer: 3

Rationale 1: These defects are not associated with blood pressures that are different in upper and lower extremities.

Rationale 2: These defects are not associated with blood pressures that are different in upper and lower extremities.

Rationale 3: Coarctation of the aorta can present with stronger pulses in the upper extremities than in the lower extremities and higher blood pressure readings in the arms than in the legs because of obstruction of circulation to the lower extremities.

Rationale 4: These defects are not associated with blood pressures that are different in upper and lower extremities.

Global Rationale:

Cognitive Level: Analyzing

Client Need:

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-3