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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
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
Rationale:
A. Placing an infant who is 5 months old in a high chair to feed is unsafe because the infant might fall or choke.
B. Positioning a 1-month-old infant supine on a soft mattress increases the risk of sudden infant death syndrome (SIDS).
C. Providing a one-piece pacifier is a safe practice since it prevents the pacifier from breaking apart and causing a choking hazard.
D. Infants should be secured in car seats that are away from airbags. Securing the infant's car seat behind an airbag is dangerous because the airbag could injure or kill the infant in a crash.
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