A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect?
Orthopnea
Bradycardia
Weight loss
Increased urine output
The Correct Answer is A
A. Orthopnea
Explanation:
Orthopnea refers to difficulty breathing that occurs when lying flat. In heart failure, fluid may accumulate in the lungs, leading to respiratory distress when the child is in a supine position. Orthopnea is a common symptom of heart failure in both adults and children.
B. Bradycardia
Explanation: Bradycardia (slow heart rate) is not a typical finding in heart failure. Heart failure often leads to compensatory mechanisms, including an increased heart rate (tachycardia), to maintain cardiac output.
C. Weight loss
Explanation: Weight loss is not a typical finding in heart failure. In fact, heart failure in children may lead to fluid retention and weight gain rather than weight loss.
D. Increased urine output
Explanation: Heart failure in toddlers is more likely to be associated with decreased urine output rather than increased urine output. Reduced cardiac output can result in decreased blood flow to the kidneys, leading to decreased urine production and potential fluid retention. Increased urine output is not a characteristic finding in heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Ribbon-like stools
Explanation: Ribbon-like or pencil-thin stools are associated with conditions affecting the rectum, such as colorectal cancer, but they are not a typical sign of intussusception.
B. Profuse projectile vomiting
Explanation: Profuse projectile vomiting is not a typical sign of intussusception. Vomiting may occur, but it is not the primary characteristic feature.
C. Bright red blood and mucus in the stools
Explanation:
Intussusception is a condition in which one part of the intestine slides into another, causing a blockage. One of the classic signs of intussusception is the presence of "currant jelly" stools, which are characterized by a mixture of bright red blood and mucus in the stools. This occurs due to the compression of the blood vessels in the intestine, leading to bleeding and mucosal discharge.
D. Watery diarrhea
Explanation: Watery diarrhea is not a typical sign of intussusception. The condition is more commonly associated with abdominal pain, vomiting, and the characteristic "currant jelly" stools.
Correct Answer is ["A","B","C","D"]
Explanation
A. The child needs to avoid exposure to other illnesses.
Explanation: Children with AIDS have compromised immune systems and are more susceptible to infections. Therefore, it is important to minimize exposure to other illnesses to reduce the risk of infections.
B. Frequent handwashing is important.
Explanation: Good hand hygiene helps prevent the spread of infections. Encouraging frequent handwashing is crucial in the care of a child with AIDS.
C. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach).
Explanation: Using a bleach solution to clean up body fluid spills helps to disinfect and reduce the risk of transmission of infections. The recommended ratio is 10 parts water to 1 part bleach.
D. Monitor the child's weight.
Explanation: Monitoring the child's weight is important for assessing nutritional status and overall health. Weight loss may indicate underlying health issues that need attention.
E. The child's immunization schedule will need revision.
Explanation: Children with AIDS may have altered immune function, but the need for immunizations is still crucial. However, live vaccines may need to be avoided. The immunization schedule should be discussed and individualized with the healthcare provider.
F. Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention.
Explanation: While these symptoms may occur, they should not be dismissed without evaluation. Any changes in the child's health, including symptoms such as fever, malaise, fatigue, weight loss, vomiting, and diarrhea, should be reported to the healthcare provider for appropriate assessment and intervention.
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