The nurse has admitted a child with a ventricular septal defect to the unit. Which of the following is an appropriate nursing diagnosis for this child?
1. Impaired gas exchange related to pulmonary congestion secondary to the increased pulmonary blood flow
2. Fluid volume, deficient related to hyperthermia secondary to the congenital heart defect
3. Acute pain related to the effects of a congenital heart defect
4. Hypothermia related to decreased metabolic state
1
Rationale:
1. Because of the increased pulmonary congestion, impaired gas exchange would be an appropriate nursing diagnosis.
2. Ventricular septal defects do not cause deficient fluid volume.
3. Ventricular septal defects do not cause pain.
4. Ventricular septal defects do not cause fever.
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