The nurse is reviewing the health history and physical examination of a child diagnosed with heart failure.
The nurse would expect to find all of the following except:
Shortness of breath when playing.
Crackles on lung auscultation.
Tiring easily when eating.
Bradycardia.
The Correct Answer is D
Choice A rationale
Shortness of breath, or dyspnea, particularly during physical activity like playing, is a classic sign of heart failure in children. This occurs due to pulmonary congestion and increased pulmonary venous pressure caused by the heart's inability to pump blood efficiently, leading to fluid backup into the lungs and reduced gaseous exchange capacity.
Choice B rationale
Crackles (rales) heard on lung auscultation are indicative of fluid accumulation in the alveoli and small airways, which results from pulmonary edema due to left-sided heart failure. This finding is a direct manifestation of the increased hydrostatic pressure in the pulmonary capillaries, causing transudation of fluid into the lung tissue.
Choice C rationale
Tiring easily when eating, often described as poor feeding or difficulty sucking, is a common symptom of heart failure in infants. This fatigue is due to the increased metabolic demands and energy expenditure required for sucking and the effort associated with early pulmonary congestion and tachypnea.
Choice D rationale
Bradycardia, an abnormally slow heart rate (normal heart rate for a school-age child is 60-100 beats/min), is generally not an expected finding in pediatric heart failure. Tachycardia (fast heart rate) is the body's compensatory mechanism to maintain adequate cardiac output in the presence of poor contractility or high volume load, and it is a typical finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Explaining food choices appropriate to the prescribed diet is important for health education and adherence to a treatment plan. However, this action primarily addresses physiological needs and compliance. While it involves the client, it does not specifically promote an adolescent's sense of identity or provide external stimulation vital for a person in this developmental stage, which heavily relies on peer interaction for self-definition and engagement.
Choice B rationale
Planning activities around scheduled rest periods supports physical recovery and compliance with medical necessity for rest. This intervention addresses energy conservation and the physiological needs of the chronically ill client. However, it does not actively encourage social interaction, personal expression, or engagement with the outside world, all of which are critical components for maintaining the sense of self and developmental needs of an adolescent.
Choice C rationale
Encouraging communicating with friends through social media is the most effective way to maintain stimulation and support the adolescent's sense of identity. Adolescents derive their self-concept heavily from peer interaction and social networking. Facilitating this contact reduces feelings of isolation, maintains social roles, and allows them to participate in their normal developmental tasks, thus bolstering their identity and emotional well-being despite hospitalization.
Choice D rationale
Teaching the name and indications for use of all medications is a key component of client education and fosters autonomy and compliance. While knowing about their treatment plan empowers the client, this task is focused primarily on health literacy and adherence. It does not provide the external stimulation or peer connection that is fundamentally necessary for an adolescent to sustain their identity and mitigate the psychological toll of chronic illness and hospitalization.
Correct Answer is D
Explanation
Choice A rationale
An X-ray is a form of imaging used to visualize bones and soft tissues, which would be ordered to assess for structural problems or infection in organs like the lungs, but it is not the primary initial test for evaluating the overall function of the immune system.
Choice B rationale
An Electrocardiogram (EKG) is a diagnostic test that records the electrical activity of the heart, used to assess cardiac rhythm and function, and it would not be the initial test to investigate a suspected disorder of the body's immune defenses.
Choice C rationale
A urine analysis is a test that examines the physical, chemical, and microscopic properties of urine, primarily used to detect conditions like urinary tract infections or renal disease, and does not provide comprehensive information on immune status.
Choice D rationale
A Complete Blood Count (CBC) is anticipated because it provides a quantitative measure of white blood cells (WBCs), red blood cells (RBCs), and platelets, offering critical initial insights into the number and differential count of leukocytes, which are the main components of the immune system.
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