Question 1

The nurse is reviewing the assessment data for a client with acute glomerulonephritis (AGN). Which of the following would be an expected finding?

Accepted Answer

Answer reason: This produces hematuria (often tea- or cola-colored) and is a classic expected assessment/urinalysis finding. Polyuria is not typical early because reduced glomerular filtration more often leads to oliguria and fluid retention. Ketonuria and glycosuria are findings more consistent with diabetes-related metabolic derangements rather than primary glomerular inflammation.

Question 2

The nurse is performing an assessment on a client suspected of having Lyme disease. Which assessment finding would support the diagnosis of Lyme disease?

Accepted Answer

Answer reason: Lyme disease (Borrelia burgdorferi) commonly presents with systemic flu-like symptoms and prominent musculoskeletal complaints, including migratory joint pain that can progress to intermittent large-joint arthritis. Joint pain fits the expected clinical pattern in early disseminated and later stages and is a typical assessment finding supporting the suspected diagnosis. Chancre lesions are characteristic of primary syphilis, not Lyme disease. A petechial rash more strongly suggests conditions like meningococcemia or rickettsial illness rather than the classic Lyme presentation.

Question 3

A client is admitted with chest pain unrelieved by nitroglycerin, an elevated temperature, decreased blood pressure, and diaphoresis. A myocardial infarction is diagnosed. Which should the nurse consider as a valid reason for one of this client's physiologic responses?

Accepted Answer

Answer reason: Tissue necrosis triggers an acute inflammatory response with cytokine release, which can reset the hypothalamic temperature set point and produce a low-grade fever after an infarction. This directly explains the client’s elevated temperature as a physiologic response to myocardial injury. Diaphoresis in acute coronary syndromes is more consistent with sympathetic activation from pain/anxiety and reduced cardiac output rather than a parasympathetic reflex. Peripheral vasoconstriction typically increases systemic vascular resistance and helps support blood pressure, whereas hypotension in MI is more often due to impaired pump function, dysrhythmias, or cardiogenic shock.

Question 4

A nurse is assigned to care for a child who is diagnosed with intussusception. Upon reviewing the child's medical record, the nurse expects to note which symptom of this condition?

Accepted Answer

Answer reason: Intussusception causes telescoping of bowel segments, leading to venous congestion, bowel wall ischemia, and mucosal sloughing. This process produces the classic “currant jelly” stool pattern of blood mixed with mucus, which is a hallmark finding nurses should anticipate. Projectile vomiting is more typical of pyloric stenosis, especially in young infants, and does not best match the key stool finding here. Tape-like stools suggest distal colonic narrowing (e.g., Hirschsprung disease or stricture), not acute bowel telescoping.

Question 5

A 5-week-old boy is admitted to the hospital for pyloric stenosis. While assessing the infant, the nurse is most likely to note which of the following?

Accepted Answer

Answer reason: This occurs classically around 3–6 weeks of age and is the hallmark assessment finding. Dehydration and weight loss can also occur but are downstream consequences and less specific than the characteristic vomiting pattern. Currant jelly stools point instead to intussusception, and significant abdominal distention is not the typical primary feature of pyloric obstruction.

Question 6

The nurse is caring for a patient with meningitis. Which of the following is the priority nursing action?

Accepted Answer

Answer reason: Bacterial meningitis is a time-critical infection where delays in effective antimicrobial therapy increase mortality and neurologic injury. Prompt IV antibiotics address the underlying cause and are the highest-impact action after meningitis is suspected/recognized, often begun immediately after obtaining needed cultures per protocol. Monitoring for increased intracranial pressure and dimming lights are supportive measures that do not treat the infection and should not delay definitive therapy. Lumbar puncture is a provider procedure and may be unsafe or delayed when elevated intracranial pressure is suspected, so it is not the nurse’s priority action over initiating treatment.

Question 7

The nurse in the emergency department assesses a client diagnosed with burns. Which observation most concerns the nurse?

Accepted Answer

Answer reason: Full-thickness (third-degree) burns destroy the epidermis/dermis and often present as white, waxy, leathery, or charred tissue with reduced or absent pain due to nerve-ending destruction. This depth of injury carries the highest immediate risk for major fluid loss, hypovolemic shock, and later complications such as infection and need for grafting. The other findings (erythema, blistering, blanching, and pain) are more consistent with superficial or partial-thickness burns, which are typically less life-threatening. Therefore, the description suggesting full-thickness injury is the most concerning assessment finding.

Question 8

A patient with a heart murmur and fever is suspected of having endocarditis. What additional finding would help confirm this suspicion?

Accepted Answer

Answer reason: These processes commonly produce small mucocutaneous hemorrhages such as petechiae, which are a classic supportive sign in a febrile patient with a new or changing murmur. A decreased white blood cell count is not typical because bacterial infection more often elevates WBCs. Beck’s triad points to cardiac tamponade, a different condition, and weight gain is nonspecific and not confirmatory.

Question 9

The nurse is assessing a client in the intensive care unit with suspected shock. What are the early signs and symptoms of neurogenic shock?

Accepted Answer

Answer reason: The fall in vascular tone leads to hypotension, and the unopposed vagal influence produces bradycardia, which distinguishes it from most other shock states. Peripheral vasodilation also prevents the usual compensatory vasoconstriction, so the skin is typically warm and dry rather than cool and clammy. Options describing tachycardia and cool, clammy skin better match hypovolemic/cardiogenic shock physiology. Hypertension is inconsistent with early neurogenic shock.

Question 10

A nurse is caring for a client with a history of migraines. Which of the following findings would support a diagnosis of migraines?

Accepted Answer

Answer reason: This option matches the core migraine pattern of pulsatile unilateral pain plus autonomic GI symptoms and focal sensory changes. Severe unilateral ocular pain with rhinitis is more consistent with cluster headache (trigeminal autonomic cephalalgia). Band-like pressure with neck pain suggests tension-type headache, even though photophobia can occasionally overlap.

Question 11

What is the most common symptom in a client with abdominal aortic aneurysm?

Accepted Answer

Answer reason: Many AAAs are asymptomatic until they expand, but when symptoms occur, abdominal pain is a classic and common complaint, sometimes with a pulsatile abdominal mass. Upper back pain is more characteristic of thoracic aortic pathology; diaphoresis is nonspecific and typically reflects acute sympathetic response such as shock. Headache is not a typical manifestation of an abdominal aortic process.

Question 12

The nurse should be aware that which condition is most likely to directly cause peritonitis?

Accepted Answer

Answer reason: A perforated peptic ulcer creates a full-thickness defect that allows acid, bacteria, and food to spill into the peritoneum, rapidly triggering chemical and then bacterial peritonitis. In contrast, cholelithiasis and gastritis typically cause localized inflammation without a direct breach into the peritoneal space unless complicated by perforation. An incarcerated hernia primarily causes bowel obstruction and ischemia; peritonitis is more indirect and usually occurs only after strangulation with necrosis and perforation.

Question 13

The nurse is assessing a client with Ménière’s disease. The nurse anticipates the assessment will identify which symptom?

Accepted Answer

Answer reason: Classic findings include vertigo, fluctuating sensorineural hearing loss, aural fullness, and ringing in the ear. This makes an auditory complaint like ringing the most expected assessment finding. The other options reflect nasal bleeding, trigeminal-type facial pain, or eyelid droop—findings not characteristic of inner-ear endolymphatic dysfunction.

Question 14

A child with tetralogy of Fallot may assume which position of comfort during exercise?

Accepted Answer

Answer reason: ” Squatting increases systemic vascular resistance, which reduces right-to-left shunting across the VSD and promotes more blood flow to the lungs for oxygenation. This position also increases venous return and can improve perfusion during acute dyspnea/cyanosis episodes triggered by activity. The other positions do not meaningfully increase systemic vascular resistance to counteract the shunt physiology during exertion.

Question 15

Which condition is one of the initial signs of lead poisoning?

Accepted Answer

Answer reason: This leads to decreased intestinal motility, making constipation a frequent initial symptom in children. Other early findings can include abdominal pain, irritability, and poor appetite, whereas severe neurologic deficits occur later with significant exposure. Anemia is a known effect of lead but is typically identified on testing rather than as an early, specific presenting symptom compared with constipation.

Question 16

Clients with insulin-dependent diabetes mellitus may require which change to their daily routine during periods of infection?

Accepted Answer

Answer reason: g., cortisol, catecholamines), which raise hepatic glucose output and increase insulin resistance. This typically leads to hyperglycemia and higher insulin requirements in insulin-dependent diabetes, and inadequate dosing increases risk for ketosis and diabetic ketoacidosis. Sick-day management generally emphasizes continuing insulin and often using supplemental/adjusted dosing based on frequent glucose and ketone checks. A common mistake is reducing insulin when oral intake drops; instead, insulin is usually maintained and adjusted while fluids and carbohydrates are managed to prevent hypoglycemia.

Question 17

A client with acute pulmonary edema caused by heart failure asks the nurse which area of the heart is usually damaged. What is the best response by the nurse?

Accepted Answer

Answer reason: When the left ventricle cannot effectively eject blood, pressure backs up into the left atrium and then the pulmonary veins and capillaries, increasing hydrostatic pressure and pushing fluid into the alveoli. This mechanism directly links pulmonary edema to left ventricular dysfunction. In contrast, right-sided failure more typically causes systemic venous congestion (e.g., peripheral edema, JVD) rather than alveolar flooding.

Question 18

The nurse is assessing a client with suspected appendicitis. The nurse would expect the client to use which of the following terms to describe their pain?

Accepted Answer

Answer reason: Clients often report pain that is persistent rather than coming and going, especially after the initial vague periumbilical discomfort migrates to the right lower quadrant. A transient or episodic pattern is more consistent with colicky pain from hollow-organ obstruction (e.g., biliary or renal colic) than appendiceal inflammation. Therefore, the expected descriptor is continuous, unrelenting pain rather than variable or short-lived sensations.

Question 19

A client is admitted with an anorectal fistula. The nurse is aware that the client most likely has which condition?

Accepted Answer

Answer reason: This feature is classic for Crohn’s because it involves the full thickness of the bowel wall and can create abnormal connections to adjacent structures or skin. Ulcerative colitis is typically limited to the mucosa/submucosa, so fistulas are uncommon. Diverticulosis is usually asymptomatic, and diverticulitis more often causes abscess or perforation rather than anorectal fistulas as the hallmark association.

Question 20

Which symptom, if reported by a client, would lead the nurse to suspect gastric cancer?

Accepted Answer

Answer reason: This symptom can be subtle and is a classic warning sign when it is persistent and progressive, especially when paired with anorexia and unintended weight loss. In contrast, abdominal cramping is more typical of intestinal spasm/irritation (e.g., gastroenteritis or IBS) rather than a primary gastric malignancy presentation. Constant hunger and weight gain are not expected red-flag patterns for gastric cancer, where decreased intake and weight loss are more common.

Question 21

The nurse is performing an assessment on a client being evaluated for viral hepatitis. Which symptom will the nurse most likely assess on this client?

Accepted Answer

Answer reason: Joint pains and myalgias are well-recognized manifestations, particularly in hepatitis B, and may occur before jaundice develops. Headache can occur with many viral illnesses but is less characteristic as a key hepatitis assessment finding compared with joint pain. Polyphagia is not typical of hepatitis and is more associated with endocrine/metabolic conditions (e.g., diabetes) than hepatic inflammation.

Question 22

A nurse is assessing a child with juvenile hypothyroidism. The nurse documents which assessment finding?

Accepted Answer

Answer reason: This commonly presents with cool, coarse, dry skin and often brittle hair. In children, hypothyroidism is more associated with slowed growth and constipation rather than increased bowel motility. Diarrhea, insomnia, and accelerated growth are more consistent with hyperthyroidism, making them less appropriate findings here.

Question 23

The nurse is assessing an infant with a suspected diagnosis of hypothyroidism. The nurse would assess the infant for which sign?

Accepted Answer

Answer reason: This reduced metabolic state also contributes to constipation and bradycardia rather than increased stooling or heart rate. Diarrhea and tachycardia are more consistent with hyperthyroidism due to increased metabolic drive. While prolonged neonatal jaundice can occur in hypothyroidism, lethargy is a more classic and broadly expected clinical sign during assessment.

Question 24

The nurse suspects that a 10-year-old client with diabetes is hyperglycemic. What symptom would indicate hyperglycemia?

Accepted Answer

Answer reason: Dehydration triggers polydipsia, making increased thirst a classic and early symptom. In contrast, hunger is more typical of hypoglycemia, and tachycardia is nonspecific and can occur with many stress states. Headache can occur with glucose abnormalities but is less specific than the dehydration-driven thirst seen in hyperglycemia.

Question 25

A nurse is caring for a neonate with congenital hypothyroidism. The nurse observes the client for which finding?

Accepted Answer

Answer reason: Periorbital edema/puffy eyelids is therefore a classic neonatal sign to monitor. Hyperreflexia is more consistent with hyperthyroidism or stimulant/toxic states; hypothyroidism typically causes lethargy and hypotonia. Tongue findings in congenital hypothyroidism are classically macroglossia rather than a small tongue, making that option inconsistent.

Question 26

Which assessment finding would indicate vaso-occlusive crisis in a child with sickle cell anemia?

Accepted Answer

Answer reason: The most typical assessment finding is severe musculoskeletal or bone pain that worsens with movement, so difficulty or pain when walking is a classic manifestation. Urinary burning suggests a urinary tract issue rather than ischemic pain, and throat pain more commonly points to an upper respiratory infection. Fever with rash suggests an infectious or inflammatory process, whereas pain is the hallmark feature of vaso-occlusion.

Question 27

A mother reports that her 4-year-old child has been scratching at his rectum recently. Which infestation or condition should the nurse suspect?

Accepted Answer

Answer reason: This presentation fits an infestation pattern rather than localized trauma or generalized skin involvement. An anal fissure more often causes pain with defecation and bright red blood on the stool or toilet tissue rather than primarily itching. Scabies typically causes widespread nocturnal itching with burrows on wrists, finger webs, or waistline, not isolated rectal scratching, and lice infest hair-bearing areas (scalp/pubic region) rather than the anus in a preschooler.

Question 28

The nurse cares for a client diagnosed with angina. Which type of angina is caused by coronary artery spasm?

Accepted Answer

Answer reason: Coronary vasospasm causes transient myocardial ischemia due to sudden narrowing of a coronary artery, often occurring at rest and producing episodic chest pain with reversible ischemic ECG changes. This mechanism defines Prinzmetal (variant) angina, which is not primarily driven by fixed atherosclerotic demand ischemia. Stable angina is typically predictable with exertion from fixed plaque-related stenosis, while unstable angina reflects plaque rupture with thrombus and worsening ischemia. Silent angina refers to ischemia without typical pain symptoms, not a specific spasm-based mechanism.

Question 29

The nurse is planning care for a client with Addison’s disease. What is the most appropriate nursing diagnosis?

Accepted Answer

Answer reason: A priority nursing diagnosis should reflect the most common, persistent patient problem that drives daily functional limitation, making decreased activity tolerance and exhaustion central. Options suggesting fluid overload are inconsistent because aldosterone deficiency more typically produces sodium and water loss with hypovolemia rather than retention. Gas exchange impairment and thermoregulation problems are not defining, expected primary problems in uncomplicated adrenal insufficiency compared with the prominent, generalized weakness and low stamina.

Question 30

The client with acute pyelonephritis of the left kidney is hospitalized. The nurse should monitor for which most frequently occurring symptom?

Accepted Answer

Answer reason: This symptom is a frequent, characteristic finding along with systemic signs such as fever and chills. Low-grade fever can occur, but pyelonephritis more typically causes higher fever and is less specific than unilateral flank pain for identifying renal involvement. Bradycardia is not an expected feature of acute bacterial kidney infection, and right lower quadrant rebound tenderness suggests an acute abdominal process (e.g., appendicitis) rather than left kidney infection.

Question 31

In alcohol-related pancreatitis, which intervention is the best way to reduce the exacerbation of pain?

Accepted Answer

Answer reason: Eliminating alcohol removes the most important precipitant for further pancreatic irritation, reducing the likelihood of pain flares and progression to chronic pancreatitis. A low-fat diet can reduce pancreatic stimulation, but it does not address the key etiologic factor in this specific condition. Supine positioning often worsens discomfort, and aspirin is not a targeted or preferred analgesic in acute pancreatitis management.

Question 32

A client is admitted with a diagnosis of hepatic encephalopathy. The nurse’s assessment documentation will include which of the following?

Accepted Answer

Answer reason: A classic bedside finding is asterixis ("liver flap"), an involuntary flapping tremor seen with arms extended and wrists dorsiflexed, reflecting impaired motor control. In contrast, hepatic encephalopathy typically causes declining attention, confusion, and somnolence rather than improved concentration or increased energy. Behavioral changes can occur, but the most characteristic, specific assessment cue among the options is the presence of asterixis.

Question 33

The nurse is developing a plan of care for a client diagnosed with rheumatoid arthritis. What is the goal of treatment?

Accepted Answer

Answer reason: The primary treatment goal is to suppress and control the inflammatory process (e.g., with DMARDs/biologics and symptom control) to reduce symptoms and slow progression. A true cure is not currently achievable, so management focuses on disease control and preventing damage. Preventing osteoporosis can be an important secondary objective (e.g., steroid-related bone loss), but it is not the central treatment goal. Bone regeneration is not a realistic primary outcome in established RA compared with limiting ongoing inflammatory injury.

Question 34

The nurse asks a client in the late stages of osteoarthritis to describe the joint pain the client is currently experiencing. The nurse anticipates that the client will describe the pain as?

Accepted Answer

Answer reason: Osteoarthritis pain results from progressive cartilage loss and mechanical joint stress, so symptoms worsen with activity and weight bearing. In later stages, the pain becomes more persistent and deeper, reflecting advanced structural degeneration and inflammation. Rest typically decreases mechanical loading and therefore provides the greatest symptom relief compared with continued movement. A “grating” sensation describes crepitus (a finding) rather than the characteristic pain quality, and “dull ache” alone is more typical of earlier, milder disease.

Question 35

Which client on the rehabilitation unit is most likely to develop autonomic dysreflexia?

Accepted Answer

Answer reason: Noxious stimuli below the level of injury (most commonly bladder distention or bowel impaction) trigger severe vasoconstriction and hypertension with reflex bradycardia and symptoms such as headache, flushing/sweating above the lesion. A high cervical lesion places the client well above the T6 threshold, making this complication particularly likely in rehab settings where urinary and bowel triggers are common. Brain injury and stroke do not create the same spinal sympathetic disconnection pattern, and herniated nucleus pulposus typically does not produce the complete high-level cord disruption associated with this syndrome.

Question 36

Which condition indicates that spinal shock is resolving in a client with C7 quadriplegia?

Accepted Answer

Answer reason: Resolution is classically marked by the return of spinal reflexes (often beginning with bulbocavernosus and later deep tendon reflexes) below the level of injury as reflex arcs regain function. Persistent sensory loss does not indicate recovery from spinal shock, because it may reflect the permanent level/completeness of injury rather than the shock phase. Spontaneous breathing relates more to diaphragmatic function (typically preserved at C7) and is not the defining sign that spinal shock is ending. Bladder function usually returns later as reflex (spastic) neurogenic bladder and does not reliably signal early resolution.

Question 37

A client recently experienced a common cold and a subsequent asthma attack. Based on the assessment findings, the nurse determines that the client is experiencing which type of asthma?

Accepted Answer

Answer reason: A “common cold” preceding wheezing and bronchospasm fits this infection-related pattern. Allergic (extrinsic) asthma is more strongly associated with exposure to specific allergens and often a history of atopy (e.g., allergic rhinitis, eczema). “Emotional” is not a standard asthma type, and “Mediated” is nonspecific and does not identify the clinically recognized classification being tested.

Question 38

A nurse is caring for a child with acute rheumatic fever. Which symptom would indicate Sydenham’s chorea?

Accepted Answer

Answer reason: This finding differentiates chorea from the cardiac manifestations of rheumatic fever. Cardiomegaly, a regurgitant murmur, and a pericardial friction rub point to carditis/valvular involvement rather than the CNS complication. Therefore, the symptom most indicative of Sydenham’s chorea is the presence of involuntary movements.

Question 39

In an infant receiving inadequate treatment for congenital hypothyroidism, the nurse should expect to observe which symptom(s)?

Accepted Answer

Answer reason: Clinically this presents as lethargy, decreased activity, and excessive sleepiness rather than hyperarousal. In contrast, irritability/jitteriness, increased appetite, and diarrhea are more consistent with excess thyroid hormone and a hypermetabolic state. Therefore ongoing fatigue and somnolence are expected when treatment is insufficient.

Question 40

Which subjective assessment finding helps diagnose human immunodeficiency virus (HIV) infection in children?

Accepted Answer

Answer reason: Recurrent or persistent diarrhea is a classic caregiver-reported symptom due to opportunistic GI infections and HIV-associated enteropathy, and it contributes to failure to thrive. In contrast, excessive weight gain and good feeding tolerance are not typical diagnostic clues because untreated pediatric HIV more often causes poor growth and nutritional compromise. Arrhythmia is not a characteristic early subjective finding for pediatric HIV and would prompt evaluation for other primary cardiac or metabolic causes.

Question 41

The nurse is assessing a child with sickle cell anemia. Which bone-related complication would the nurse be alert for during assessment?

Accepted Answer

Answer reason: During assessment, joint pain, swelling, and limited range of motion can occur as part of these ischemic bone/joint complications. In contrast, primary osteoporosis and spontaneous fractures are not classic, expected pediatric complications directly associated with sickling crises. Osteogenic sarcoma is unrelated to the underlying hemoglobinopathy and would not be a typical complication pattern to anticipate.

Question 42

The nurse is assessing a child who has been admitted to the emergency department with a diagnosis of tuberculosis. Which symptom would the nurse expect to observe?

Accepted Answer

Answer reason: This finding fits classic pediatric TB manifestations (e.g., cervical or hilar node involvement) more directly than nonspecific systemic symptoms. Chills are more characteristic of acute bacterial infections and are not a typical hallmark symptom emphasized for TB assessment. Weight gain contradicts the expected chronic illness pattern, where poor weight gain or weight loss is more likely, and hyperactivity is not a TB-related symptom.

Question 43

The nurse is admitting a client who is diagnosed with hyperthyroidism. The client asks what can be done for this disorder. What is the best response by the nurse?

Accepted Answer

Answer reason: Radioactive iodine selectively concentrates in thyroid cells and ablates overactive tissue, making it a common definitive treatment for many causes of hyperthyroidism. Oral thyroid hormones would worsen the condition because they increase circulating thyroid hormone. Lithotripsy targets kidney or gall stones, and laryngectomy is not a treatment for thyroid hormone overproduction.

Question 44

The nurse teaches the parents of the child diagnosed with Addison’s disease signs of addisonian crisis. Which sign identified by the parents indicates that further teaching is needed?

Accepted Answer

Answer reason: This produces hypotension and hypovolemic shock risk, often accompanied by GI symptoms such as abdominal pain and signs of dehydration. Severe hypertension is the opposite of the expected hemodynamic finding, so reporting it as a crisis sign reflects misunderstanding. While severe electrolyte derangements can contribute to neurologic symptoms, the hallmark hemodynamic pattern is low blood pressure rather than high.

Question 45

A client has developed acute respiratory distress syndrome (ARDS). What is the priority nursing diagnosis for the client?

Accepted Answer

Answer reason: The immediate life-threatening problem is inadequate oxygenation/ventilation at the alveolar level, so the priority diagnosis focuses on restoring effective oxygen and carbon dioxide exchange. Infection risk, poor nutrition, and skin breakdown are important but are secondary to stabilizing oxygenation and preventing respiratory failure. Prioritization follows ABCs, making oxygenation the most urgent physiologic need in ARDS.

Question 46

The nurse is aware that which diagnosis is most likely to contribute to the development of acute respiratory distress syndrome (ARDS)?

Accepted Answer

Answer reason: Major blunt or penetrating injury with shock, tissue damage, and massive transfusion risk can trigger this inflammatory cascade and is a well-known precipitant of ARDS. In contrast, conscious sedation more commonly risks hypoventilation or aspiration events rather than initiating the diffuse inflammatory lung injury pattern of ARDS. Localized conditions like a meniscus injury do not create the widespread physiologic insult needed to precipitate ARDS.

Question 47

Which assessment is expected by the nurse when assessing a child with tetralogy of Fallot?

Accepted Answer

Answer reason: When the child cries or becomes active, systemic vascular resistance can drop and/or infundibular spasm can worsen outflow obstruction, increasing right-to-left shunting. This produces acute “tet spells” with worsening cyanosis and hypoxemia that is classically triggered by agitation or exertion. A common distractor is the machinelike murmur, which is more characteristic of patent ductus arteriosus, not tetralogy of Fallot. Upper-extremity higher pressures than lower suggests coarctation of the aorta rather than TOF.

Question 48

A child with tetralogy of Fallot has clubbing of the fingers and toes. The nurse is aware that the clubbing is most likely to be caused by?

Accepted Answer

Answer reason: Clubbing results from long-standing tissue hypoxemia that triggers vascular connective tissue changes and increased blood flow to the distal digits. In tetralogy of Fallot, right-to-left shunting decreases pulmonary oxygenation and produces persistent systemic desaturation, making this finding expected over time. Polycythemia is a compensatory response to low oxygen levels and may coexist, but it is not the primary mechanism causing the clubbing. A murmur reflects turbulent flow, and growth/development issues can occur in cyanotic heart disease, but neither directly explains the digital structural changes seen with clubbing.

Question 49

Which assessment finding would the nurse commonly assess in a child with truncus arteriosus?

Accepted Answer

Answer reason: This turbulence commonly produces a prominent systolic murmur, and truncal valve insufficiency can add a regurgitant quality. The other options are less characteristic: narrowed pulse pressure is more suggestive of low stroke volume states, and “pink and moist mucous membranes” does not reflect the expected mixing lesion physiology that often leads to cyanosis and heart failure signs. Therefore, an abnormal harsh systolic murmur is a typical assessment finding in this condition.

Question 50

An infant has been diagnosed with tricuspid atresia. Which surgical intervention should a nurse expect the physician to recommend?

Accepted Answer

Answer reason: This single-ventricle physiology is addressed with staged repairs culminating in the Fontan circulation, which separates systemic and pulmonary circulations and reduces cyanosis. A Blalock-Taussig shunt may be used as an earlier temporizing step to increase pulmonary blood flow, but it is not the definitive operation expected for this defect. The Jatene procedure is for transposition of the great arteries, and patch closure is typically used for isolated septal defects rather than single-ventricle outflow routing.

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