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
Explanation
A. Limit alcohol and caffeine intake. This is important for bone health and overall well-being during menopause, especially since alcohol and caffeine can affect bone density.
B. Decreasing the intake of dairy products. While calcium intake is important, decreasing dairy intake is not a recommended strategy during menopause unless there are specific dietary restrictions or intolerances.
C. Performing regular weight-bearing exercises. This is important for maintaining bone density but may not be the most important measure compared to limiting alcohol and caffeine intake.
D. Taking vitamin E and B complex vitamin supplements. While vitamins are important, they are not as critical as lifestyle measures like limiting alcohol and caffeine.
Correct Answer is B
Explanation
A. Ensuring that the client takes care of their ADLS to prevent dependence: While promoting independence is important, ensuring safety is a higher priority to prevent immediate harm.
B. Ensuring that the client environment is safe to prevent injury: Safety is the top priority for clients with Alzheimer's due to their increased risk of falls, wandering, and other accidents. A safe environment helps prevent injuries.
C. Ensuring that the client receives food they like to prevent anxiety: Although providing familiar and preferred foods can reduce anxiety, it is not as critical as ensuring a safe environment.
D. Ensuring that the client meets the other patients to prevent social isolation: Social interaction is beneficial, but ensuring safety takes precedence to prevent potential harm.
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