The nurse is providing care to a child with a congenital heart defect.
Which of the following would lead the nurse to suspect that the child is developing heart failure?
Bradypnea.
Inability to sweat.
Acral edema.
Splenomegaly.
The Correct Answer is C
Choice A rationale
Bradypnea, which is an abnormally slow respiratory rate, is not a typical initial or hallmark sign of developing heart failure in a child. Instead, tachypnea (an increased respiratory rate) is commonly observed as the body attempts to compensate for pulmonary congestion or decreased cardiac output, making bradypnea an unlikely finding.
Choice B rationale
Inability to sweat, known as anhidrosis, is usually associated with conditions affecting the nervous system or sweat glands, such as certain genetic disorders or severe dehydration. This symptom is not a characteristic clinical manifestation of heart failure, which primarily involves impaired cardiac function and circulatory congestion leading to respiratory and edema symptoms.
Choice C rationale
Acral edema, which is swelling of the hands and feet, is a classic sign of systemic venous congestion resulting from the failing heart's inability to effectively pump blood forward. This pooling of fluid in the periphery is a key indicator that a child with a congenital heart defect may be developing new or worsening right-sided heart failure.
Choice D rationale
Splenomegaly, or enlargement of the spleen, is a nonspecific finding often seen in chronic venous congestion from heart failure, but also in many other conditions, including infections and hematological disorders. It is not one of the most common or earliest signs of heart failure in a child, which often presents first with signs like tachypnea, poor feeding, or periorbital edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A preference for certain toys is a common, non-pathological finding in toddlers as they develop individual interests and preferences. While extreme rigidity in play or an inability to shift focus may be concerning, simple preference alone does not typically indicate a significant developmental delay in a 30-month-old child, but rather a normal expression of autonomy. Further assessment would involve observing the quality and functional use of play.
Choice B rationale
Food selectivity or "picky eating" is a very frequent and normal developmental phase during toddlerhood, often peaking around age two to five years, and is not usually indicative of a neurological or pervasive developmental disorder. A child's refusal to frequently try new foods, especially in the absence of weight loss or growth failure, is not an immediate alarm for developmental delay.
Choice C rationale
Restlessness in a structured public setting like a restaurant with a waiting period is an expected behavior for a 30-month-old toddler due to their limited attention span and developmental need for gross motor activity and immediate gratification. This is a common age-appropriate reaction to boredom and constraint, not a sign of major developmental pathology.
Choice D rationale
At 30 months old, a child's expressive language milestone should significantly exceed "one or two words" and grunting. The expected milestone for this age is a vocabulary of 50 or more words and the ability to combine two to three words into short phrases or sentences (e.g., "Mommy go"). This finding strongly suggests a language delay warranting immediate comprehensive developmental evaluation.
Correct Answer is D
Explanation
Choice A rationale
Jogging involves high-impact, repetitive loading on the joints of the lower extremities, specifically the hips, knees, and ankles. This type of high-impact exercise can exacerbate inflammation and cause further articular damage in a child diagnosed with Juvenile Idiopathic Arthritis (JIA), thus it is generally discouraged to prevent joint trauma.
Choice B rationale
Jumping rope is considered a high-impact, plyometric activity that places significant stress on multiple joints, including the ankles, knees, and hips, due to the forceful landings. This impact can aggravate the symptoms of JIA, such as joint pain and swelling, and contribute to progressive cartilage and bone erosion over time.
Choice C rationale
Tennis is a sport that involves rapid, jarring movements, quick changes in direction, and high impact on weight-bearing joints, as well as repetitive, forceful movements in the wrists, elbows, and shoulders. These actions can increase mechanical stress and shearing forces on inflamed joints, making it an unsuitable exercise choice for a child with JIA.
Choice D rationale
Swimming is an excellent form of exercise for children with JIA because the buoyancy of the water provides a non-weight-bearing environment, significantly reducing the impact and stress on inflamed joints. This allows for improved range of motion, muscle strengthening, and cardiovascular conditioning without increasing joint pain or damage.
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