Which of the following is an early sign of congestive heart failure that the nurse should recognize?
Increased urine output
Tachypnea
Bradycardia
Inability to sweat
The Correct Answer is B
A. Increased urine output is not typical in early congestive heart failure (CHF); in fact, decreased urine output can occur due to reduced kidney perfusion.
B. Tachypnea (rapid breathing) is an early and key sign of CHF in children. It occurs due to pulmonary congestion and decreased cardiac output, leading to poor oxygenation and compensatory increased respiratory rate.
C. Bradycardia is a late and often ominous sign of cardiac deterioration in children, not an early indicator.
D. Inability to sweat is not a recognized clinical indicator of CHF. On the contrary, diaphoresis (especially during feeding in infants) can be an early sign.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Frequent swallowing is a classic sign of post-tonsillectomy hemorrhage, as the child may be swallowing blood that is draining down the throat. This can be a subtle but early indicator of bleeding and requires immediate evaluation.
B. Increased pain is expected in the immediate postoperative period and not specific to hemorrhage.
C. Drooling may be due to throat pain or refusal to swallow but is not a key indicator of bleeding.
D. Poor fluid intake is common after tonsillectomy due to pain and discomfort, but not specific to hemorrhage.
Correct Answer is D
Explanation
A. A vanilla milkshake contains dairy, which can coat the throat and cause coughing or throat clearing, potentially leading to bleeding.
B. Orange juice is acidic and can irritate the surgical site, causing pain and discomfort.
C. Cranberry juice, while not as acidic as orange juice, can still be irritating due to its tartness, especially in the early postoperative phase.
D. Crushed ice is ideal shortly after a tonsillectomy. It helps keep the throat moist, provides soothing relief, and poses minimal risk of irritation or bleeding. It is often recommended as one of the first oral intake options post-op.
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