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.
Tachycardia
Dyspnea
Weight loss
Cyanosis
Bounding peripheral pulses
Correct Answer : A,B,D
A. Tachycardia: Tachycardia (increased heart rate) is a common compensatory mechanism in heart failure as the heart tries to pump more effectively.
B. Dyspnea: Dyspnea is a common symptom of heart failure due to fluid accumulation in the lungs.
C. Weight loss: Weight gain, rather than weight loss, is more commonly associated with heart failure due to fluid retention. Therefore, weight loss is not an expected finding.
D. Cyanosis: Cyanosis can occur in heart failure due to poor oxygenation and circulation.
E. Bounding peripheral pulses: Bounding peripheral pulses are not typically associated with heart failure. Heart failure often results in weak or thready pulses due to poor cardiac output.
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Related Questions
Correct Answer is D
Explanation
A. Hematemesis (vomiting blood): Hematemesis (vomiting blood) is not typically associated with celiac disease. It is more commonly seen in conditions like gastrointestinal bleeding, ulcers, or esophageal varices.
B. Increased hemoglobin level: Celiac disease can lead to malabsorption of nutrients, including iron, which often results in anemia and decreased hemoglobin levels rather than increased hemoglobin levels.
C. Redcurrant, jelly-like stools: Redcurrant jelly-like stools are characteristic of intussusception, not celiac disease. Intussusception is a condition where part of the intestine folds into another section, leading to obstruction and characteristic stools.
D. Pale, oily stools: Pale, oily (steatorrhea) stools are a common finding in celiac disease. This is due to malabsorption of fats caused by damage to the small intestine's lining, leading to the excretion of undigested fats in the stool.
Correct Answer is B
Explanation
A. Follows airborne precautions by wearing an N95 respirator while caring for the child: Pertussis requires droplet precautions, not airborne precautions. An N95 respirator is not necessary.
B. Maintains droplet precautions while the child is coughing and sneezing: Correct. Droplet precautions are appropriate for pertussis, which is spread through respiratory droplets. These precautions help prevent the transmission of the infection.
C. Wears gloves when assisting the child to the bathroom: While wearing gloves is a standard precaution, it does not specifically address the droplet transmission route of pertussis. Gloves alone are not sufficient for preventing the spread of pertussis.
D. Applies a face mask after entering the child's room: The face mask should be applied before entering the room to ensure the nurse is protected from respiratory droplets immediately upon entry.
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