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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. "I am unable to discuss this, but I can contact my supervisor to speak with you."
Explanation: While it is appropriate to involve a supervisor in difficult situations, the nurse should first clarify the legal obligation to report suspected child abuse. This response may leave the impression that the nurse is avoiding the question.
B. "As a nurse, I am required by law to report suspected child abuse."
Explanation:
Nurses are mandated reporters, meaning they are legally obligated to report suspected child abuse. It is important to communicate this legal obligation to the parents when they inquire about the reason for the report. This response is honest, direct, and reinforces the nurse's ethical and legal responsibility to prioritize the well-being and safety of the child.
C. "I reported the incident to my supervisor who decided to contact the authorities."
Explanation: This response may create confusion about the reporting process. It is important to convey that reporting is a legal obligation for the nurse, and it is not solely at the discretion of the supervisor.
D. "The provider will be coming to explain the situation."
Explanation: While involving other healthcare professionals, such as a provider, may be part of the process, it is crucial to emphasize the nurse's legal responsibility to report suspected child abuse. This response does not clearly communicate the legal obligation that the nurse has in reporting such incidents.

A. Stopping the medication when the child feels better B. Written information about the medication C. The reason why the child is taking the medication D. Using a kitchen spoon to administer the medication E. The adverse effects of the medication

Correct Answer is ["B","C","E"]

Explanation

A. Stopping the medication when the child feels better: Antibiotics should be taken for the full prescribed course, even if the child starts feeling better. Stopping prematurely can lead to incomplete eradication of the infection and potential antibiotic resistance.
B. Written information about the medication: Providing written information about the medication helps reinforce verbal instructions and serves as a reference for the parents or caregivers.
C. The reason why the child is taking the medication: It is essential to explain to parents or caregivers the purpose of the medication, such as treating a specific infection. Understanding the reason for the medication promotes compliance.
D. Using a kitchen spoon to administer the medication: Using a kitchen spoon can result in inaccurate dosing. The nurse should recommend using an appropriate measuring device, such as a calibrated oral syringe or a dosing spoon, to ensure accurate dosage administration.
E. The adverse effects of the medication: Educating parents or caregivers about potential adverse effects helps them monitor for any signs of complications and seek medical attention if needed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

Correct Answer is B

Explanation

A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic. Which of following information should the nurse include in the discharge instructions? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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