The nurse is collecting data on a 2 month-old-child with left-sided congestive heart failure. Which clinical manifestation would support this diagnosis of left-sided congestive heart failure?
Edema in the lower extremities
Ascites
Shortness of breath
Hepatomegaly
The Correct Answer is C
A. Edema in the lower extremities:
Incorrect: Edema in the lower extremities is more characteristic of right-sided heart failure. In left-sided failure, pulmonary congestion is more prominent.
B. Ascites:
Incorrect: Ascites, or fluid accumulation in the abdominal cavity, is also more commonly associated with right-sided heart failure.
C. Shortness of breath:
Correct Answer: Left-sided congestive heart failure can lead to pulmonary congestion, resulting in difficulty breathing or shortness of breath. This is often observed as increased work of breathing, rapid breathing, or other signs of respiratory distress in infants.
D. Hepatomegaly:
Incorrect: Hepatomegaly, or enlargement of the liver, is another manifestation more commonly associated with right-sided heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Administer prednisone on an alternate-day schedule.
Explanation: Prednisone, a corticosteroid, is often prescribed to manage inflammation and symptoms in juvenile idiopathic arthritis. An alternate-day schedule helps minimize the risk of side effects associated with prolonged corticosteroid use.
B. Apply cool compresses for 20 minutes every hour.
Incorrect: While cool compresses can provide relief for joint pain associated with arthritis, applying them every hour may be excessive and is not a standard recommendation. It's important to use cooling measures judiciously.
C. Encourage the child to take a 45-minute nap daily.
Incorrect: While adequate rest is important for overall health, suggesting a specific duration for a nap may not be universally applicable. The child's need for rest and sleep should be based on individual factors, and a specific time frame is not a standard recommendation for juvenile idiopathic arthritis.
D. Allow the child to stay at home on days when her joints are painful.
Incorrect: While it's important to consider the child's comfort and well-being, keeping the child at home solely on days of joint pain may not be necessary. The goal is to manage symptoms effectively to allow participation in normal daily activities, including school. Restricting activities solely based on joint pain is not the typical approach to managing juvenile idiopathic arthritis.
Correct Answer is C
Explanation
A. Ribbon-like stools
Explanation: Ribbon-like or pencil-thin stools are associated with conditions affecting the rectum, such as colorectal cancer, but they are not a typical sign of intussusception.
B. Profuse projectile vomiting
Explanation: Profuse projectile vomiting is not a typical sign of intussusception. Vomiting may occur, but it is not the primary characteristic feature.
C. Bright red blood and mucus in the stools
Explanation:
Intussusception is a condition in which one part of the intestine slides into another, causing a blockage. One of the classic signs of intussusception is the presence of "currant jelly" stools, which are characterized by a mixture of bright red blood and mucus in the stools. This occurs due to the compression of the blood vessels in the intestine, leading to bleeding and mucosal discharge.
D. Watery diarrhea
Explanation: Watery diarrhea is not a typical sign of intussusception. The condition is more commonly associated with abdominal pain, vomiting, and the characteristic "currant jelly" stools.
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