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 B
Explanation
A. The child is too young to receive antibiotics: This statement doesn't address the actual reason for not prescribing antibiotics for croup, which is primarily due to its viral nature.
B. "Antibiotics are not indicated unless a bacterial infection is present."
Explanation:
Viral laryngotracheobronchitis, commonly known as croup, is typically caused by a viral infection, most commonly by the parainfluenza virus. Antibiotics are not effective against viruses. Therefore, unless a bacterial infection is also present, prescribing antibiotics is not necessary or beneficial in treating croup.
C. The child may be allergic to antibiotics: While antibiotic allergies are a consideration, it doesn't explain why antibiotics are not prescribed for viral illnesses like croup.
D. The child still has the maternal antibodies from birth and does not need antibiotics: Maternal antibodies can offer some protection against infections, but the primary reason for not using antibiotics in viral infections like croup is because antibiotics are ineffective against viruses.
Correct Answer is D
Explanation
A. "Carry a water bottle with me because I drink a lot of water."
Explanation: Staying hydrated is crucial, especially for individuals with paralysis who may be prone to urinary issues. Carrying a water bottle is a good practice to maintain adequate hydration.
B. "Use a suppository every night to have a bowel movement."
Explanation: Using a suppository for regular bowel movements is a positive self-care behavior. It helps manage bowel care, which is important for individuals with paralysis.
C. "I do wheelchair exercises while watching TV."
Explanation: Engaging in wheelchair exercises to maintain mobility is a positive self-care behavior. It helps prevent complications related to being sedentary, such as muscle atrophy.
D. "I only need to catheterize myself twice every day."
Explanation: This statement may indicate a need for further teaching. Individuals with paralysis, especially due to conditions like spina bifida, often have neurogenic bladder dysfunction. They typically require more frequent catheterization, potentially every 4-6 hours, to ensure adequate bladder emptying and reduce the risk of complications like urinary tract infections (UTIs) or bladder infections.
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