A nurse is caring for a pediatric patient with congestive heart failure (CHF). What major goal should the nurse include in the care of this patient?
Prevent contractures of his hips and knees.
Minimize his cardiac output.
Minimize his energy expenditure.
Prevent vomiting.
The Correct Answer is C
Choice A rationale:
Preventing contractures of the hips and knees is not directly related to the care of a pediatric patient with congestive heart failure (CHF). CHF primarily involves impaired cardiac function and fluid retention, not joint contractures.
Choice B rationale:
Minimizing cardiac output would be counterproductive in the care of a patient with CHF. The goal is to optimize cardiac output to meet the body's demands while managing the symptoms of CHF.
Choice C rationale:
Minimizing energy expenditure is a major goal in the care of a pediatric patient with CHF. CHF places an extra workload on the heart, and conserving energy helps prevent additional strain on the heart, allowing it to function more efficiently.
Choice D rationale:
Preventing vomiting is not a specific goal related to the care of a pediatric patient with CHF. Vomiting might be a symptom of CHF, but the primary focus is on managing cardiac function and fluid balance.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Waiting to discuss the surgery until the child asks specific questions might lead to increased anxiety as the child may be apprehensive about the surgery but unable to express their concerns.
Choice B rationale:
Setting aside an hour a day to talk about the child's feelings concerning the surgery can be overwhelming for a 5-year-old, potentially increasing anxiety and making the procedure seem more daunting.
Choice C rationale:
Reading the child a story about children of similar age who go to the hospital for surgery provides a developmentally appropriate approach. It helps the child understand the process through relatable characters, reducing fear and uncertainty about the upcoming experience.
Choice D rationale:
Having the child visit a family whose preschool child has just been discharged from the hospital might expose the child to unfamiliar situations, possibly leading to more confusion and anxiety.
Correct Answer is D
Explanation
Choice D rationale:
Monitoring the cardiac catheterization site for bleeding is the priority nursing intervention when a child feels nauseous and vomits after a cardiac catheterization. Bleeding from the catheterization site could lead to serious complications and requires immediate attention.
Choice A rationale:
Applying a cool cloth to the child's forehead can provide comfort, but it doesn't address the potential complication of bleeding from the catheterization site.
Choice B rationale:
Offering the child sips of orange juice is not appropriate if the child is nauseous and vomiting. Fluid intake should be monitored, but bleeding assessment takes priority.
Choice C rationale:
Applying pressure to the cardiac catheterization site is not the priority intervention. Monitoring for bleeding and assessing the site are more important.
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