A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect?
Orthopnea
Bradycardia
Weight loss
Increased urine output
The Correct Answer is A
A. Orthopnea
Explanation:
Orthopnea refers to difficulty breathing that occurs when lying flat. In heart failure, fluid may accumulate in the lungs, leading to respiratory distress when the child is in a supine position. Orthopnea is a common symptom of heart failure in both adults and children.
B. Bradycardia
Explanation: Bradycardia (slow heart rate) is not a typical finding in heart failure. Heart failure often leads to compensatory mechanisms, including an increased heart rate (tachycardia), to maintain cardiac output.
C. Weight loss
Explanation: Weight loss is not a typical finding in heart failure. In fact, heart failure in children may lead to fluid retention and weight gain rather than weight loss.
D. Increased urine output
Explanation: Heart failure in toddlers is more likely to be associated with decreased urine output rather than increased urine output. Reduced cardiac output can result in decreased blood flow to the kidneys, leading to decreased urine production and potential fluid retention. Increased urine output is not a characteristic finding in heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
A. Symptoms are continuous throughout the day:
Incorrect: Continuous symptoms throughout the day are more indicative of moderate or severe persistent asthma, not mild persistent asthma.
B. Daytime symptoms occur more than twice a week:
Correct Answer: Children with mild persistent asthma may experience symptoms more than twice a week, but less than once a day.
C. Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value:In mild persistent asthma, pulmonary function tests (e.g., PEF or FEV1) remain normal or close to normal, with values typically ≥80% of the predicted value, reflecting good lung function between episodes.
D. Nighttime symptoms occur approximately twice a month:
Mild persistent asthma often involves nighttime symptoms or awakenings occurring 3–4 times per month. If nighttime symptoms occur more frequently (e.g., once weekly), it suggests moderate persistent asthma.
E. Minor limitations occur with normal activity:Children with mild persistent asthma may experience minor limitations in their normal activities. These limitations are not severe and do not significantly impact daily life.
Correct Answer is D
Explanation
A. Administer 0.9% sodium chloride IV solution: Although IV fluids might be necessary to maintain hydration and circulation, this is not the priority over preventing the spread of infection.
B. Assist with obtaining an x-ray of the child's neck.Imaging can help confirm the diagnosis but should be done after ensuring infection control measures.
C. Initiate IV antibiotics.Antibiotics are crucial for treatment but should follow the implementation of droplet precautions to prevent the spread of infection.
D. Place the child on droplet precautions.
Epiglottitis is a medical emergency primarily caused by bacterial infections, such as Haemophilus influenzae type B (Hib). The first priority is to ensure the safety of both the patient and others by preventing the spread of infection.Placing the child on droplet precautions helps to contain the bacteria and protect healthcare workers and other patients.
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