A nurse is caring for a school-age child who has heart failure. Which of the following interventions should the nurse implement?
Ensure that the child sleeps in an air-conditioned room.
Avoid giving the child live virus vaccines.
Weigh the child every other day.
Consolidate activities to promote the child's rest.
The Correct Answer is D
A. Ensure that the child sleeps in an air-conditioned room: While a cool and comfortable environment may reduce stress and promote rest, air conditioning alone does not address the management of heart failure. It is supportive but not a priority nursing intervention.
B. Avoid giving the child live virus vaccines: Live virus vaccines are typically avoided in immunocompromised clients or those on immunosuppressive therapy, not specifically for stable pediatric heart failure.
C. Weigh the child every other day: Children with heart failure are at risk for fluid retention, and daily weights provide the accurate and timely assessment of fluid status. Weighing every other day could delay the identification of fluid overload and compromise early intervention.
D. Consolidate activities to promote the child's rest: Children with heart failure often experience fatigue due to decreased cardiac output. Organizing care to allow longer rest periods helps reduce cardiac workload and conserves energy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"E"}
Explanation
Rationale for correct choices
• Increased intracranial pressure: Meningitis causes inflammation of the meninges, which restricts cerebrospinal fluid flow and leads to cerebral edema. Symptoms such as headache, lethargy, irregular respirations, and nuchal rigidity point toward elevated ICP risk.
• Seizures: CNS irritation from infection increases neuronal excitability. The child’s fever, irritability, and lethargy make them especially prone to seizures, which are a common complication in pediatric bacterial meningitis.
Rationale for incorrect choices
• Disseminated intravascular coagulation: Although petechiae are present, DIC is not the most immediate or common complication in meningitis. It is more often linked to meningococcemia with fulminant sepsis rather than early bacterial meningitis.
• Hydrocephalus: This may occur in chronic or untreated meningitis, but it is not the most acute risk. The more pressing concerns are cerebral edema and ICP elevation rather than long-term ventricular dilation.
• Hypothermia: The child currently has fever and chills, indicating hyperthermia. Hypothermia may occur in overwhelming sepsis or late-stage shock, but it is not the primary complication expected at this stage.
Correct Answer is ["A","B","E","F","G","H","I"]
Explanation
Rationale for Correct Choices
- Toddler is irritable: Irritability in a young child is a red flag for worsening systemic illness, dehydration, or early hypoxia, and requires close observation and intervention.
- Oral mucosa dry: This is a classic clinical sign of dehydration. It indicates that the toddler's body is losing more fluids than it's taking in, leading to a fluid volume deficit.
- Temperature 39.6° C (103.2° F): A persistent high fever in a toddler increases the risk of dehydration and febrile seizures. It requires prompt intervention with antipyretics and fluids to prevent further complications.
- Blood pressure 88/42 mm Hg: This is hypotension for a 2-year-old, suggesting compromised perfusion. Immediate action is needed as this can indicate progressing dehydration or early septic shock.
- Heart rate 150/min: Tachycardia in toddlers may indicate dehydration, fever, or compensatory response to low blood pressure. If unaddressed, it can progress to cardiovascular instability.
- Capillary refill 3 seconds: Prolonged refill indicates poor peripheral perfusion, which often accompanies dehydration or hypovolemia. This is a red flag for impaired circulation and worsening shock.
- Weight loss from 12 kg to 11.3–11.4 kg: A loss of nearly 6% body weight in a short period is clinically significant dehydration in a toddler. This requires prompt fluid replacement to avoid further decline.
Rationale for Incorrect Choices
- Respiratory rate 28/min: This rate is within the normal range for a 2-year-old (20–30 breaths/min). Without distress, retractions, or desaturation, it does not require immediate follow-up.
- Oxygen saturation 96% on room air: This is an acceptable oxygen level in a toddler. There are no signs of hypoxemia or respiratory compromise requiring intervention.
- Apical heart rate regular, no murmur: A regular rhythm without abnormal sounds indicates stable cardiac function. No immediate follow-up is required here.
- Lung sounds clear in all fields: The absence of wheezing, crackles, or diminished sounds rules out acute respiratory distress, so no intervention is immediately required.
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