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
Explanation
A. It is inconclusive
Explanation: A serum phenylalanine level within the normal range is considered conclusive in ruling out phenylketonuria. Inconclusive results typically occur when there are issues with the sample or testing process.
B. It is negative
Explanation:
A serum phenylalanine level of 1 mg/dL (60.5 mcmol/L) in a 2-week-old infant is within the normal range. In the context of phenylketonuria (PKU) screening, a "negative" result means that the phenylalanine levels are within the expected range, and there is no evidence of phenylketonuria.
C. It requires rescreening at age 6 weeks.
Explanation: If the initial screening result is within the normal range, rescreening at age 6 weeks may not be necessary for phenylketonuria. The timing and need for rescreening may vary based on local protocols and individual patient factors.
D. It is positive
Explanation: A positive result for phenylketonuria would indicate that the serum phenylalanine levels are elevated, suggesting a potential diagnosis of PKU. In this case, the result is negative, meaning there is no evidence of PKU.
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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