The infant with congestive heart failure has a need for:
Low protein diet to minimize energy expenditure
Increased caloric intake to manage failure to thrive
No added salt diet to minimize fluid overload
Decreased intake to treat fluid overload
The Correct Answer is B
Choice A reason: A low protein diet is not recommended for infants with congestive heart failure. Protein is essential for growth and development, as well as for tissue repair and immune function. Infants with congestive heart failure may have increased protein needs due to increased metabolic rate, fluid loss, and tissue breakdown. A low protein diet may worsen their nutritional status and compromise their recovery.
Choice B reason: Increased caloric intake is a key intervention for infants with congestive heart failure who have failure to thrive. Failure to thrive is a condition in which an infant does not gain weight or grow normally. It can be caused by congestive heart failure due to poor appetite, increased energy expenditure, poor absorption, or increased losses of nutrients. Increased caloric intake can help improve the infant's growth and development, as well as reduce the workload of the heart.
Choice C reason: A no added salt diet is advisable for infants with congestive heart failure, but it is not the most important need. Salt or sodium can cause fluid retention and worsen the symptoms of congestive heart failure, such as edema, shortness of breath, and fatigue. A no added salt diet can help prevent fluid overload and reduce the need for diuretics. However, infants with congestive heart failure still need some sodium for normal body functions, and a very low sodium diet may be harmful.
Choice D reason: Decreased intake is not a need for infants with congestive heart failure, but rather a potential problem. Decreased intake can result from poor appetite, nausea, vomiting, or difficulty feeding due to respiratory distress or fatigue. Decreased intake can lead to dehydration, electrolyte imbalance, malnutrition, and poor growth. Decreased intake should be monitored and corrected by providing frequent, small, and high-calorie feedings, as well as supplemental fluids and electrolytes as needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Suctioning the mouth and nasopharyngeal passages is the most important priority for airway care after a cleft palate repair. This is because the infant may have blood, mucus, or secretions in the mouth or nose that can obstruct the airway and cause breathing difficulties. Suctioning can help clear the airway and prevent aspiration, infection, or hypoxia.
Choice B reason: Cleaning the suture line with normal saline is an important part of wound care after a cleft palate repair, but it is not the most important priority for airway care. Cleaning the suture line can help prevent infection, promote healing, and reduce scarring. However, it should be done gently and carefully, as not to disturb the sutures or cause bleeding.
Choice C reason: Elevating the head of the bed 30 degrees is a helpful measure to facilitate breathing and drainage after a cleft palate repair, but it is not the most important priority for airway care. Elevating the head of the bed can help reduce swelling, congestion, and pressure on the surgical site. However, it should be done with caution, as not to cause neck flexion or extension that may compromise the airway.
Choice D reason: Giving IV morphine for pain is a necessary intervention to provide comfort and analgesia after a cleft palate repair, but it is not the most important priority for airway care. Giving IV morphine can help relieve the pain and distress that the infant may experience after the surgery. However, it should be given with close monitoring, as it may cause respiratory depression, sedation, or hypotension.
Correct Answer is C
Explanation
Choice A reason: This is not a correct statement, as coarse breath sounds, abnormal ECG, and joint pain are not typical signs and symptoms of Kawasaki disease. Coarse breath sounds may indicate respiratory infection or congestion, abnormal ECG may indicate cardiac arrhythmia or damage, and joint pain may indicate arthritis or inflammation¹.
Choice B reason: This is not a correct statement, as murmur, tachycardia, and low erythrocyte sedimentation rate are not typical signs and symptoms of Kawasaki disease. Murmur may indicate a heart valve problem, tachycardia may indicate fever or dehydration, and low erythrocyte sedimentation rate may indicate anemia or inflammation¹.
Choice C reason: This is the correct statement, as fever, "strawberry tongue", and peeling palms and soles are typical signs and symptoms of Kawasaki disease. Fever is the most common symptom, lasting for more than five days and not responding to antibiotics or antipyretics. "Strawberry tongue" is a term used to describe the red, swollen, and cracked appearance of the tongue. Peeling palms and soles are a late sign, occurring in the second or third week of the illness¹².
Choice D reason: This is not a correct statement, as abdominal pain, vomiting, and restlessness are not typical signs and symptoms of Kawasaki disease. Abdominal pain and vomiting may indicate gastrointestinal infection or irritation, and restlessness may indicate discomfort or anxiety¹.
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