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. "I will limit my child's fluid intake."
Incorrect: Limiting fluid intake is not typically recommended for children with CF. Maintaining hydration is important, especially since individuals with CF may have increased salt losses in sweat.
B. "We will give our child pancreatic enzymes with snacks and meals."
Correct Answer: This response indicates an understanding of the importance of giving pancreatic enzymes to assist with digestion, as individuals with CF often have pancreatic insufficiency. Pancreatic enzymes help in the absorption of nutrients from food.
C. "We will restrict the amount of salt in our child's food."
Incorrect: While it's true that individuals with CF may need to increase their salt intake due to increased salt losses in sweat, this response suggests restricting salt, which is not in line with the nutritional needs of a child with CF.
D. "I will prepare low-fat meals with limited protein for my child."
Incorrect: Children with CF often need a higher calorie intake, including healthy fats and adequate protein. Restricting fat and protein is not in line with the nutritional needs of a child with CF.
Correct Answer is A
Explanation
A. "Has the child had any difficulty swallowing food?"
Explanation:
Cleft palate repair can impact various aspects of a child's development, and one potential long-term effect is difficulty with swallowing or feeding. This question is relevant to assessing the child's oral and feeding function, which can be influenced by the cleft palate repair.
B. "Does the child play with an imaginary friend?"
Explanation: Imaginary play and social interactions are not directly related to the long-term effects of cleft palate repair. This question focuses more on social and imaginative development.
C. "Does the child respond when called by name?"
Explanation: Responsiveness to one's name is a general developmental milestone and is not directly related to the long-term effects of cleft palate repair.
D. "Was the child recently treated for pneumonia?"
Explanation: While respiratory issues can be a concern in children with a history of cleft palate, this question is more specific to recent health issues and does not address the long-term effects of cleft palate repair.
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