What assessment(s) in a child with tetralogy of Fallot would indicate the child is experiencing a paroxysmal hypercyanotic episode? (Select all that apply.)
a. Spontaneous cyanosis
b. Dyspnea
c. Weakness
d. Dry cough
e. Syncope
ANS: A, B, C, E
Indicators of a paroxysmal hypercyanotic episode or a "tet" episode are spontaneous cyanosis, dyspnea, weakness, and syncope.
You might also like to view...
The nurse is preparing the patient for a thoracentesis. What must be completed before the procedure may be performed?
a. Physical assessment b. Interview c. Informed consent d. Surgical checklist
The nurse is caring for a 5-year-old child diagnosed with hypothyroidism whose mother voices skepticism about giving the child drugs
In explaining the need for medication, what will the nurse tell this mother could result if her daughter's condition remains untreated so she can make an informed decision? A) Mental retardation B) Renal dysfunction C) Immune deficiency D) Paralytic ileus
For which of the following patients would it be most important to obtain an apical-radial pulse and calculate the pulse deficit? A patient who:
a. Had abdominal surgery 2 hours ago b. Suffered a fractured hip yesterday c. Is dehydrated from vomiting d. Has a heart or lung disease
Which statement by a patient would the nurse not expect to find with a diagnosis of posttraumatic stress disorder (PTSD) as a result of a motor vehicle accident?
A) "I keep seeing the accident in my dreams." B) "I find that I am avoiding riding in cars." C) "I startle easily with loud noises." D) "I find myself emotionally expressive."