A nurse is caring for a client with a congenital heart disease who is prescribed digoxin. The nurse should instruct the client to report which symptom immediately?
Weight gain of 1 pound in a week.
Heart rate below 100 beats per minute.
Occasional episodes of diarrhea.
Mild swelling of the ankles after activity.
The Correct Answer is A
A) The answer is A. Weight gain of 1 pound in a week can indicate fluid retention, which may be a sign of digoxin toxicity. The nurse should instruct the client to report this symptom immediately to prevent further complications.
B) Incorrect. A heart rate below 100 beats per minute is within the normal range for most clients. A lower heart rate is often expected in clients taking digoxin, and it does not require immediate reporting unless accompanied by other concerning symptoms.
C) Incorrect. Occasional episodes of diarrhea are common side effects of digoxin. The client should report persistent or severe diarrhea, but occasional episodes may not be a cause for immediate concern.
D) Incorrect. Mild swelling of the ankles after activity is not directly related to digoxin use. The nurse should monitor the client's ankles for any worsening swelling, but it does not require immediate reporting unless accompanied by other concerning symptoms.
The answer is A
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Related Questions
Correct Answer is D
Explanation
A) Incorrect. Not all congenital heart diseases resolve on their own. While some may improve over time, it is essential for the client to follow their healthcare provider's recommendations for monitoring and treatment.
B) Incorrect. While breastfeeding has many benefits for infants, it may not directly impact the congenital heart disease. The nurse should focus on educating the client about managing the specific heart condition.
C) Incorrect. Avoiding vaccinations and routine check-ups is not recommended. Regular check-ups and vaccinations are crucial for overall health, and the healthcare provider will guide the client regarding any specific precautions or modifications needed due to the heart condition.
D) The answer is D. Clients with congenital heart diseases are at increased risk of infections, so it is essential to educate the client about infection prevention measures, such as limiting contact with other children during times of increased risk.
Correct Answer is A
Explanation
A) The answer is A. The pallor and coolness of the skin may indicate poor cardiac output and impaired circulation commonly seen in congenital heart diseases. These signs are suggestive of reduced oxygen delivery to peripheral tissues.
B) Incorrect. The respiratory rate being within the normal range does not specifically point to a congenital heart disease. Other signs and symptoms should be assessed to confirm the diagnosis.
C) Incorrect. The closure and firmness of the fontanelle are related to the status of the infant's skull bones and do not directly indicate congenital heart disease.
D) Incorrect. Weight gain following the growth chart percentile for age is not directly associated with congenital heart diseases. There are more specific clinical indicators to consider in the assessment of this condition.
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