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 D
Explanation
Choice A reason: This is not the correct order, as obtaining blood cultures should be done after starting high dose antibiotics, not before. This is because antibiotics can interfere with the detection of bacteria in the blood and affect the accuracy of the diagnosis¹.
Choice B reason: This is not the correct order, as administering high dose steroids is not indicated for infective endocarditis, unless there is evidence of severe inflammation or allergic reaction. Steroids can suppress the immune system and increase the risk of infection².
Choice C reason: This is not the correct order, as starting the child on high dose aspirin is not recommended for infective endocarditis, unless there is evidence of thromboembolic complications or Kawasaki disease. Aspirin can increase the risk of bleeding and interfere with the action of antibiotics³.
Choice D reason: This is the correct order, as starting high dose antibiotics, obtaining serial blood cultures, and putting the child on high flow oxygen are the appropriate interventions for infective endocarditis. Antibiotics are the main treatment to eradicate the infection and prevent complications. Serial blood cultures are done to monitor the response to antibiotics and identify the causative organism. High flow oxygen is given to improve the oxygen delivery and tissue perfusion¹².
Correct Answer is A
Explanation
Choice A reason: Hydrostatic reduction of telescoped bowel with an air or saline enema is the treatment of choice in a child with intussusception who is not showing signs of sepsis or shock. Intussusception is a condition in which a part of the intestine slides into another part, causing obstruction, inflammation, and ischemia. Hydrostatic reduction is a procedure that uses air or saline to create pressure in the colon and push the intussuscepted segment back to its normal position. It is a safe, effective, and minimally invasive method that can avoid surgery and its complications.
Choice B reason: False is not the correct answer, as hydrostatic reduction of telescoped bowel with an air or saline enema is the treatment of choice in a child with intussusception who is not showing signs of sepsis or shock. Surgery is only indicated if hydrostatic reduction fails or is contraindicated, or if the child has signs of perforation, peritonitis, or shock.
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