A two-month-old infant is hospitalized for repair of a ventricular septal defect. The infant's admitting diagnosis is moderate congestive heart failure. What signs and symptoms would you expect to see in your assessment?
Bradycardia, bounding pulses, cyanosis
Overdiuresis, increased appetite, increased thirst
Wheezing, pallor, capillary refill time < 2 seconds
Tachypnea, cough, tachycardia
The Correct Answer is D
Choice A reason: This is not a correct statement, as bradycardia, bounding pulses, and cyanosis are not typical signs and symptoms of moderate congestive heart failure. Bradycardia may indicate a heart block or a vagal response, bounding pulses may indicate a patent ductus arteriosus or aortic regurgitation, and cyanosis may indicate a severe right-to-left shunt or a pulmonary embolism¹.
Choice B reason: This is not a correct statement, as overdiuresis, increased appetite, and increased thirst are not typical signs and symptoms of moderate congestive heart failure. Overdiuresis may indicate a renal dysfunction or a diuretic overdose, increased appetite may indicate a normal growth spurt or a metabolic disorder, and increased thirst may indicate dehydration or diabetes¹.
Choice C reason: This is not a correct statement, as wheezing, pallor, and capillary refill time < 2 seconds are not typical signs and symptoms of moderate congestive heart failure. Wheezing may indicate a bronchospasm or an asthma attack, pallor may indicate anemia or shock, and capillary refill time < 2 seconds may indicate a normal or increased peripheral perfusion¹.
Choice D reason: This is the correct statement, as tachypnea, cough, and tachycardia are typical signs and symptoms of moderate congestive heart failure. Tachypnea may indicate a respiratory distress or a pulmonary edema, cough may indicate a fluid accumulation or an infection in the lungs, and tachycardia may indicate a compensatory mechanism or a cardiac arrhythmia¹².
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not an appropriate intervention. Anger and aggression are not normal behaviors in preschoolers, regardless of their gender. They may indicate underlying emotional or developmental issues that need to be addressed.
Choice B reason: This is not an adequate intervention. Talking to the preschool teacher may provide some information about the child's behavior, but it does not address the root cause or offer any solutions. The nurse should collaborate with the teacher and the parents to develop a plan of care for the child.
Choice C reason: This is the most appropriate intervention. A professional psychosocial assessment can help identify the factors that contribute to the child's anger and aggression, such as family stress, trauma, mental health problems, or learning difficulties. The assessment can also provide recommendations for treatment and support for the child and the family.
Choice D reason: This is not a helpful intervention. Consistent and firm discipline is important for any child, but it may not be enough to change the child's behavior if there are other underlying issues. Moreover, harsh or punitive discipline may worsen the child's anger and aggression. The parent should be encouraged to use positive reinforcement, empathy, and problem-solving skills with the child.
Correct Answer is B
Explanation
Choice A reason: Placing the infant in Trendelenburg position (head lower than feet) after eating is not a good suggestion to minimize reflux. This position may increase the abdominal pressure and the risk of aspiration. The infant should be placed in an upright or semi-upright position (30 to 45 degrees) for at least 30 minutes after feeding to reduce reflux and prevent regurgitation¹.
Choice B reason: Thickening the formula with rice cereal is a common and effective suggestion to minimize reflux. The rice cereal increases the viscosity and weight of the formula, making it less likely to flow back into the esophagus. The amount of rice cereal added should be about 1 teaspoon per ounce of formula, unless otherwise instructed by the health care provider².
Choice C reason: Giving continuous nasogastric tube feedings is not a necessary or desirable suggestion to minimize reflux. Nasogastric tube feedings are used for infants who have severe reflux and cannot tolerate oral feedings, or who have other medical conditions that require tube feeding. Nasogastric tube feedings may have complications such as infection, irritation, displacement, or obstruction of the tube. They may also interfere with the infant's oral development and bonding with the caregiver³.
Choice D reason: Giving larger, less frequent feedings is not a helpful suggestion to minimize reflux. Larger feedings may overfill the stomach and increase the pressure on the lower esophageal sphincter, which is the muscle that prevents reflux. Less frequent feedings may also make the infant more hungry and irritable, and cause more crying and swallowing of air. The infant should be given smaller, more frequent feedings to reduce reflux and promote digestion.
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