NCLEX 3 CV DEFECTS

Congenital heart defects

Classification:

1.Acyanotic heart defects
Oxygenated blood is shunted from the systemic to pulmonary circulation (left-to-right shunt) and blood leaving the aorta is completely oxygenated.
Increased blood volume on right side of heart results in hypertrophy of right ventricle.
Eventually, most acyanotic heart defects will result in CHF.

2.Cyanotic heart defects
Unoxygenated blood is shunted from the right to the left side of the heart where it mixes with oxygenated blood.
The blood pumped to the peripheral tissues has a much lower oxygen content than normal, causing the bluish color called cyanosis.

1. Infant in CHF- highest priority is maintaining adequate fluid balance.

2. Difference of cyanotic and acyanotic defects: pulse oximeter does not read over 93% ( n =95 and above)

3. Tetralogy of fallot- cyanotic-tet spell- most important set up on bed side= oxygen set-up.

4. infants BP is very hight- initial action of nurse?= measure the cuff , should be 2/3 of the humerus.

5. 10 yr old with VSD for cardiac cath= highest priority for assessment is : pedal pulses. Breath sounds are

priority but pedal pulses is more a priority since the procedure is invasive(circulation).

NCLEX PEDIA 2

1. Celiac Disease: 9 y.o for appendectomy wuith celiac disease: avoid cleansing enema, heat to the abdomen.It will cause perforation to the appendix.

2. Diet of cleints with celiac disease is gluten free foods( crackers are not)

3. The nurse is testing reflexes in a four-month-old infant as part of the neurologic assessment. Which of the following findings would indicate an abnormal reflex pattern and an area of concern in a four-month-old infant?
1. Hyperextends toes in response to stroking sole of foot upward.
2. Does not extend and abduct extremities in response to loud noise.
3. Closes hand tightly when palm is touched.
4. Begins strong sucking movements when mouth area is stimulated.

Answer: 3.The palmar grasp is present at birth. The palmar grasp lessens by age three months and is no longer reflexive. The infant is able to close hand voluntarily.

4. What is the effect of ALL on bone Marrow: Crowding out of normal bone marrow cells.

5.
The mother of a three-month-old infant asks the nurse when she can start feeding her baby solid food. Which of the following should the nurse include in teaching this mother about the nutritional needs of infants?

1.Infant formula or breast milk provides adequate nutrients for the first year.
2. Infant cereal can be introduced by spoon when the extrusion reflex fades.
3. Pureed food can be offered when the infant has tripled his birth weight.
4.Solid foods should be given as soon as the infant's first tooth erupts.

Answer: 2 .Infant cereal is generally introduced first because of its high iron content. The infant is able to accept spoon feeding at around four to five months when the tongue thrust or extrusion reflex fades.

6. The nurse is assessing a six-month-old infant during a well child visit. The nurse makes all of the following observations. Which of the following assessments made by the nurse is an area of concern indicating a need for further evaluation?
1. Moderate head lag when pulled to sitting position.
2. Three pound weight gain in two months.
3. Closed posterior fontanel.
4. Absence of Moro reflex

Answer Rationale:1.
By four to six months, head control is well established. There should be no head lag when infant is pulled to a sitting position by the age of six months.

NCLEX PEDIA

1. Hydrocephalic child with myelomeningocele ; shunting done.
whats the best position post-op: on abdomen to keep the pressure off the spinal sac with legs abducted.

2.Hydrocephalic child: you know the shunting is functional if : there is a decrease in head circumference( csf is draining).

3. viral meningitis: s/s include fever, irritability, and stiffness of neck 9 nuchal rigidity.

4. Family of pt. of with meningitis: to promote successful coping, the nurse should: reinforce information about child's condition and plan of treatment.

5. what is the priority discharge teaching for pt. with meninigits: call physician if fever is more than 2 days.

6.6 year old hit by a car: with head injury. Nurse is doing neur assessment. what is the best information for neuro assessment: pt.'s usual behavior and status( as a baseline data).

7. A/s of a child philip: eyes sluggish and dilated: damage to parasymphatetic system. Pupils small and reactive to light: damage to diencephalon.

8.

In planning care for a child with newly diagnosed sickle cell anemia, his mother should be taught that vaso-occlusive crises may be prevented by

1. promoting hydration. 2. prophylactic administration of acetaminophen. 3. eating food with a high iron content. 4. exercising regularly.

Promoting good hydration is a major factor in maintaining the blood viscosity needed to maximize the circulation of red blood cells. Good hydration can help to minimize the severity of symptoms should the child develop sickle cell crisis. Acetaminophen would not be helpful in decreasing the sickling process. Iron administration would be of no value because in sickle cell anemia there is an abnormally shaped hemoglobin. The problem is not due to iron deficiency. Regular exercise is important for children with sickle cell disease, but it will not prevent a vaso-occlusive crisis.

More pedia tips later! 9/26/07

Manila escapade

Hello there! i made a respite to rest and pack all my bags to manila with my sellers! September 13-16,2007 was the memorable date.

That friday, we trooped to makati. specifically, we went malling ( glorietta, megamall)...we also scanavenged in what they call the shopper's haven- 168 mall in divisoria! then we headed all the way to the humongous mall of asia...maybe should be renamed mall of the world...due to its sheer size!

To add more details later!

WELCOME TO MY WORLD

WELCOME TO MY WORLD!