A one month old infant is admitted for confirmation of the diagnosis of ventricular septal defect. During the initial admission assessment, the nurse would expect to find:

Correct Answer: D

Rationale: A ventricular septal defect (VSD) is a congenital heart defect where there is an abnormal opening between the two ventricles of the heart. One of the hallmark signs of VSD is the presence of a murmur, specifically a holosystolic murmur, which is typically heard best at the left sternal border due to the turbulent blood flow through the defect. This murmur is a key finding during the initial assessment of a patient with a suspected VSD. Other common symptoms of VSD include poor feeding, failure to thrive, tachypnea, and frequent respiratory infections.

Correct Answer: D

Rationale: Wilms tumor can grow very quickly, so a lump that was not evident previously may become noticeable in a short period.

Correct Answer: B

Rationale: Drinking cranberry juice can help decrease the odor of urine due to its acidic nature. The acid in cranberry juice can help neutralize odors in the urine, making it less noticeable. In contrast, consuming spicy foods (choice A) can actually increase the odor of urine. Similarly, choices C and D (eating eggs, asparagus, or cheese; drinking tea, coffee, and colas) can contribute to stronger-smelling urine due to the compounds they contain. Therefore, recommending cranberry juice to the male client with a stomal pouch is the most appropriate choice to help him remain odor-free.

Correct Answer: C

Rationale: When an adult is on a clear liquid diet, foods that are easy to digest and leave little residue in the gastrointestinal tract are recommended. Clear liquids include water, broth, fruit juices without pulp, and gelatin desserts like Jello. Jello is a good option because it is easily digestible, does not leave residue, and provides some calories and hydration. Milk, orange juice, and ice cream should be avoided on a clear liquid diet as they are not considered clear liquids and may not be as easily digestible.

Correct Answer: D

Rationale: Cruising typically occurs later, around 9-10 months.