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A nurse is caring for a school-age child who has heart failure. Which of the following findings should the nurse expect?Select all that apply.

Cyanosis

Weight loss

Bounding peripheral pulses

Dyspnea

Tachycardia

Answer and Explanation

Correct Answer : A,D,E

Rationale:

A. Cyanosis can occur in children with heart failure due to inadequate oxygenation of tissues.

B. Weight gain or fluid retention is more common in children with heart failure.

C. Bounding pulses are more commonly associated with conditions such as hypertension or hyperthyroidism, rather than heart failure.

D. Dyspnea, or difficulty breathing, is a common symptom of heart failure due to fluid buildup in the lungs.

E. Tachycardia, or a rapid heart rate, can occur as a compensatory mechanism in response to decreased cardiac output in heart failure.

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Correct Answer is C

Explanation

Rationale:

A. Nuchal rigidity when standing may indicate meningitis, but it is not a common complication of lumbar puncture itself.

B. Double vision is not a typical complication of lumbar puncture and suggests other neurological issues.

C. Headache is a common complication of lumbar puncture, occurring due to leakage of cerebrospinal fluid (CSF) from the puncture site. It is often described as positional, worsening when the patient sits or stands upright and improving when lying down.

D. Pain in the posterior iliac crest is not a typical complication of lumbar puncture and may indicate musculoskeletal issues unrelated to the procedure.

A. While osteomyelitis is a serious condition requiring treatment, receiving an IV bolus of nafcillin is not an urgent procedure compared to a neurological symptom like slurred speech. B. Pain management is important, but a pain level of 7, while significant, does not indicate an immediate life-threatening situation. C. Slurred speech in an adolescent with sickle cell anemia could indicate a neurological complication or a stroke, which requires immediate assessment and intervention. D. Although the toddler with a partial-thickness burn needs care, it is not as urgent as assessing a potential neurological issue like slurred speech.

Correct Answer is C

Explanation

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A nurse is caring for a school-age child who has heart failure. Which of the following findings should the nurse expect?Select all that apply.

Nursing Test Bank

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Correct Answer is C

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