CJ is a 16-year-old high school student who is in the clinic for a sports physical prior to beginning basketball practice. He has no known significant medical history, takes no medications, and has no allergies. Subjective data reveal only that CJ is short of breath earlier than most boys on the team. He attributes this to needing to get into better physical condition. The physical exam is unremarkable except for a grade III systolic murmur heard over the entire precordium. An echocardiogram and cardiac catheterization reveal a ventricular septal defect (VSD) with moderate pulmonary hypertension. 1. A VSD is usually an acyanotic defect. Why is this?
2. What is the mechanism of pulmonary hypertension? What may result if it is prolonged?
3. What other disorders besides VSD can produce a systolic murmur? How can character of the murmur and pattern of radiation be used to differentiate among the etiologic factors?
4. Is it necessary to close a VSD? What are the common complications of untreated VSD?

Mr smith a 52 year old patient, is admitted to the coronary care unit with the diagnosis of acute inferior myocardial infarction. the patient has a history of smoking two packs of cigarettes for 35 years, and he drinks a six pack of beer on weekend nights, but does not drink the rest of the week. he is the sole financial support for his family. he is a consultant for a company and is out of town during the week days. mr smith has gained 20 pounds. he is 5 foot, 6 inches, weighing 200 pounds. his diet consists mostly of fast foods. he rarely exercise. his wife care for their three teenage children. the eldest son, 17 years of age, totaled the family car when drinking and driving 2 days ago and he is in the local children’s hospital in the intensive care unit in critical condition. mr smith developed chest pains and slumped over in his chair during an argument with his wife about their teenage daughter, who is 15 years of age and wanted to get birth control pills. the wife is in the waiting room while the nurses settle mr smith into his room. the youngest son, 13 years of age, is at a friends house. the teenage daughter is staying at the bedside of the criticall i’ll eldest son. the wife blames her eldest son for her husband’s heart attack and told the emergency department nurse that she does not care to see her son i’ll. a. what maladaptive response to stress may have contributed to mr smith’s development of an illness b. based on the case study, what family assessment data may be used to determine coping strategies being currently used by the family. c. what nursing interventions should be used to promote effective coping for the patient and his family?