Which nursing assessments are important when evaluating an infant with heart failure?
(Select All that Apply.)
Monitoring for tachycardia
Observing for diaphoresis during feeding
Monitoring for polyuria
Checking for hyperthermia
Assessing for hepatomegaly
Evaluating feeding difficulties
Correct Answer : A,B,E,F
A. Monitoring for tachycardia – Correct. Tachycardia is an early sign of heart failure as the heart attempts to compensate for decreased cardiac output.
B. Observing for diaphoresis during feeding – Correct. Infants with heart failure often exhibit sweating while feeding due to increased effort and oxygen demand.
C. Monitoring for polyuria – Incorrect. Infants with heart failure are more likely to have oliguria due to poor perfusion, not excessive urination.
D. Checking for hyperthermia – Incorrect. Fever is not a primary sign of heart failure unless an infection is present.
E. Assessing for hepatomegaly – Correct. Hepatomegaly occurs due to systemic venous congestion, a hallmark of right-sided heart failure.
F. Evaluating feeding difficulties – Correct. Poor feeding and failure to thrive are common in infants with heart failure due to fatigue and respiratory distress.
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Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Provide frequent and routine verbal updates with the parents. – Correct. Keeping parents informed can help alleviate anxiety.
B. Encourage the parents to participate in the toddler's plan of care when appropriate. – Correct. Involvement can help them feel more in control and engaged.
C. Perform more frequent health care rounds on the toddler. – Incorrect. While rounding is beneficial, it does not directly address parental distress.
D. Conduct interprofessional rounds at the child's bedside so the parents can be included. – Correct. This allows parents to hear updates directly from the care team.
E. Provide education to the parents on all nursing interventions to alleviate added anxiety about tasks they are unfamiliar with. – Correct. Education helps parents feel more comfortable with their child's care.
F. Provide the parents with the nurse's personal cell phone number to contact if they have questions while they are away from the hospital. – Incorrect. Professional communication should go through appropriate hospital channels.
Correct Answer is D
Explanation
A. "The blood supply to the bone is disrupted." – Incorrect. While fractures can affect blood flow, the main concern with epiphyseal plate fractures is growth impairment.
B. "The younger the child, the longer the healing process will take." – Incorrect. Younger children heal faster than older children or adults due to active bone remodeling.
C. "Bone marrow can be lost through the fracture." – Incorrect. Epiphyseal fractures do not cause bone marrow loss.
D. "Normal bone growth can be affected." – Correct. The epiphyseal plate is responsible for bone growth, and injury to this area can lead to growth disturbances or limb length discrepancies.
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