Which assessment findings would alert the nurse to an infant or child in heart failure? (Select All that Apply.)
Tachypnea
Wheezes or rales
Bounding pulses
Edematous
Difficulty feeding
Increased comfort laying down
Correct Answer : A,B,D,E
A. Tachypnea. Rapid breathing can indicate respiratory distress associated with heart failure.
B. Wheezes or rales. These are abnormal breath sounds indicating fluid in the lungs, which can occur with heart failure.
C. Bounding pulses. Bounding pulses are not typically associated with heart failure; weak pulses may be present due to poor perfusion.
D. Edematous. Edema can occur due to fluid retention, a sign of heart failure.
E. Difficulty feeding. Poor feeding can result from decreased cardiac output affecting systemic circulation and energy for feeding.
F. Increased comfort laying down. Children with heart failure often prefer sitting upright due to respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E","F"]
Explanation
A. Substance use. Parents or caregivers who use substances are more likely to abuse children due to impaired judgment and increased stress levels.
B. Extreme stress. High levels of stress in the family can increase the risk of child abuse as it can lead to frustration and inappropriate coping mechanisms.
C. High socioeconomic background. This is not typically associated with increased risk of child abuse; abuse can occur across all socioeconomic levels, but certain stressors are more prevalent in lower socioeconomic contexts.
D. Strong support system. A strong support system typically acts as a protective factor against child abuse by providing resources and emotional support to caregivers.
E. Prematurity. Premature infants often have increased care needs, which can lead to parental stress and potential abuse.
F. Chronic illness. Children with chronic illnesses may require more care, leading to caregiver stress and higher risk of abuse.
Correct Answer is ["A","B","C","E"]
Explanation
A. Maintain a thermoneutral environment: Helps prevent temperature fluctuations that can stress the heart post-surgery.
B. Accurately measure all intake and output: Ensures fluid balance is carefully monitored to prevent fluid overload or dehydration.
C. Provide for several periods of uninterrupted rest: Reduces metabolic demand, aiding in recovery and healing.
D. Incentive spirometer 10 times every hour: Inappropriate for infants following cardiac surgery, as they are unable to effectively use an incentive spirometer.
E. Encourage periods of bonding: Supports emotional well-being and aids in the infant's overall recovery and development.
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