A nurse is reinforcing teaching with a parent of an infant who has a new diagnosis of heart failure. Which of the following findings should the nurse include as an expected manifestation of this disease?
Increased urinary output
Tachycardia
Bounding peripheral pulses
Increased blood pressure
The Correct Answer is B
Choice A reason:
Increased urinary output is not typically associated with heart failure. In fact, heart failure often leads to decreased urine output due to decreased cardiac output.
Choice B reason:
Tachycardia (rapid heart rate) is a common manifestation of heart failure in infants. The heart compensates for decreased cardiac output by beating faster.
Choice C reason:
Bounding peripheral pulses are not typically associated with heart failure. In fact, weak peripheral pulses may be a sign of decreased cardiac output.
Choice D reason:
Increased blood pressure is not typically associated with heart failure in infants. Instead, infants with heart failure may have low or normal blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Diminished pulses can be indicative of decreased cardiac output, as it suggests that there may be a reduction in the volume of blood being pumped by the heart.
Choice B reason:
Extremities warm to touch is not necessarily indicative of decreased cardiac output. It may be related to other factors, such as ambient temperature or local blood flow.
Choice C reason:
Capillary refill of 2 seconds is within the normal range for a preschooler, and it is not a strong indicator of decreased cardiac output.
Choice D reason:
A blood pressure of 112/66 mm Hg is within the normal range for a preschooler and is not a strong indicator of decreased cardiac output.
Correct Answer is B
Explanation
Choice A reason:
A blood glucose level of 220 mg/dL is elevated and should be addressed, but it may not be an immediate priority compared to the presence of Kussmaul respirations.
Choice B reason.
Correct. Kussmaul respirations are a sign of diabetic ketoacidosis (DKA), a severe complication of diabetes. This requires immediate attention and intervention.
Choice C reason:
Vomiting is a concerning symptom, but it may not be as immediately life-threatening as Kussmaul respirations.
Choice D reason:
Frequent urination is a common symptom of diabetes, but it may not require immediate intervention unless it is accompanied by other severe symptoms.
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