HESI Case Study Congenital Heart Disease – Flashcards
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Which clinical manifestations would the nurse expect to assess in an infant diagnosed with a ventricular septal defect?
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Tachypnea and grunting with intercostal retractions
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What statement by Teresa supports billy's diagnosis of CHF?
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Billy never sems to get full even when I breastfeed him for a long time
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Teachings about post procedure care for cardiac catheterization:
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Explain they will need to hold them in the prone position after the procedure
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What actions should the nurse implement?
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Notify the cardiologistand do not allow AAron to sign
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What nursing diagnosis is important to include in the plan (parents worried heis not eating enough, losing wt)
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imbalanced nutrition:less than body requirements
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which member of the perinatal team will best be able to assist the nurse? (Mother worried about whetherbreast milk is best)
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cert lactation specialist CLC
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Which measure will be most valuable to assess the infants response to each feeding?
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SaO2 changes during feeding
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What intervention would you implement prior to administering first dose of Lanoxin?
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Obtain apical pulse to determine within the guidelines of written order (Don't give if > 90)
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When should you give a dose of Digoxin how many hours before a routine lab test?
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give a regular dose of medication at least 6 hours prior to the test
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If patient starts to choke, turn blue, and goes limp what is the first intervention you would do?
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Attempt to stimulate patients breathing by rubbing the sole of his foot
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Billy is lethargic and irritable, with a SpO2of 90% - what should the nurse do next?
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administer O2 and stay with him
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what data supports the nurse's response that he is growing on targert for 4 month old?
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plays with feet and puts them in mouth
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what activity should the nurse include as appropriate for a 4 month old?
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read brightly colored books to him
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what stage of erikson's is he at?
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trust vs mistrust
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what action is most theraputic when she finds the mother crying?
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stand by her, says "I can seeyou are upset, would you liketo talk?"
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mother expresses guilt and concern over baby's condition
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it is unknown why VSD hapens, but being a working mother is not a risk factor
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What to say when asked to respond about alternative therapy?
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should consult doctor before allowing him to take any herbal treatments
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A man arriveds claiming to be the family priest and asks about billy
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Billy's room number is 410. I think mr adams is in there. I would be happy to walk you there.
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Nursing plan of care for patient diagnosed with "Decreased Cardiac Output":
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Assess infants's peripheral pulses and capillary refill time
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what nursing task can be delegated to UAP?
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sit with billy while teresa takes a shower
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whichprescription for care should be questioned?
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digoxin 12.5 mg IVP twice daily
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Which intervention should you include when teaching parents about administration of Digoxin?
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Advise parents to administer meds about 20 - 30 minutes before the infant is fed
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which statements by aaron indicate CPR teaching is effective
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will perform chest compressions before breaths, and will do 30 complressions then 2 breaths
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billy is to be discharged. teresa and aaron work outside the home, teresa plans to quit. how do you respond?
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discuss them attending a support group
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What type of feedings does a infant with CHF need to have?
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Small concentrated feedings
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which preoperative intervention has a priority (parents are frightened)
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offer verbal and written info about the surgery
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what does the cardiopulmonary machine bypass do?
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takes over for the heart and lungs during surgery
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additional assessment data warranting immediate intervention?
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apicalpulse88, serum potassium 2.6mEq/L
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lab results requiring attention
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hgb 8/gtt
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plan ofcare info addressing fluid/electrolyte imbalance?
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monitor glucose
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intervention to address regarding his pain
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explain continuous IV of pain meds with prn bolus willcontrol pain
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what info should be included as part of his discharge?
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pat incision dry, do not rub until healed
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what statement indicates teaching has been effective?
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we will resume his regular meal, sleep and playtimes as soon as we get home
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Why do you need to use a soft nipple with a large hole to feed?
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Will be able to suck more easily and not get tired from eating
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What should you expect to see as manifestations of Heart Failure in an child?
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Cool Extremities Peripheral Edema Nasal Flaring
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Ventricular Septal Defect (VSD) Clinical manifestations:
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Left to right shunting tachypnea, dyspnea Poor growth Palpable thrill Systolic murmur at left lower sternal border
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Which manifestations would you expect to find in a child with Rheumatic Fever?
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Erythema Marginatum Elevated C-reactive protein Uncoordinated movements of extremities Two or more major Jones criteria
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What does digoxin do for the heart?
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Improves myocardial contractility
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What is the hallmark sign of digitoxicity?
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Vomiting
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Why is glucose important to the heart?
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It is important for cardiac contractability
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Rids body of excess fluid and sodium:
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Lasix
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Increases tissue oxygenation:
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Oxygen
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Improves myocardial contractility:
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Digoxin
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Reduces Afterload:
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Captopril
