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A nurse is caring for a school-age child who has heart failure. Which of the following findings should the nurse expect?Select all that apply.

Cyanosis

Weight loss

Bounding peripheral pulses

Dyspnea

Tachycardia

Answer and Explanation

Correct Answer : A,D,E

Rationale:

A. Cyanosis can occur in children with heart failure due to inadequate oxygenation of tissues.

B. Weight gain or fluid retention is more common in children with heart failure.

C. Bounding pulses are more commonly associated with conditions such as hypertension or hyperthyroidism, rather than heart failure.

D. Dyspnea, or difficulty breathing, is a common symptom of heart failure due to fluid buildup in the lungs.

E. Tachycardia, or a rapid heart rate, can occur as a compensatory mechanism in response to decreased cardiac output in heart failure.

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Correct Answer is C

Explanation

Rationale:

A. Storing opened vials of insulin for up to 60 days is incorrect. Insulin should be discarded after the manufacturer's recommended expiration date or within 28 days after opening, whichever comes first.

B. Physical therapy is not typically indicated as part of routine care for adolescents with type 1 diabetes mellitus. However, regular physical activity is encouraged for overall health and blood sugar management.

C. Consulting with a nutritionist is important for adolescents with type 1 diabetes mellitus to receive individualized meal planning guidance, carbohydrate counting education, and dietary recommendations to help manage blood sugar levels.

D. Monitoring capillary blood glucose daily is essential for adolescents with type 1 diabetes mellitus, but it is not the only recommendation. Comprehensive diabetes management includes multiple aspects such as insulin therapy, dietary modifications, physical activity, and regular monitoring of blood glucose levels.

A. Instruct the parent to ensure the pneumococcal vaccine is current. B. Administer folic acid as prescribed. C. Monitor oxygen saturation continuously. D. Place the client on strict bed rest. E. Apply cold compresses to the affected joints. F. Administer meperidine IV for pain. G. Restrict oral intake. H. Give oral hydroxyurea.

Correct Answer is ["A","B","C","F","H"]

Explanation

Rationale:

A.Clients with sickle cell disease are at increased risk for infections, including those caused by pneumococcus. Ensuring vaccination status helps prevent future complications.

B. Folic acid supplementation may be part of the overall management of sickle cell disease, but it is not a priority intervention during a vaso-occlusive crisis.

C. Vaso-occlusive crises can lead to tissue hypoxia due to impaired blood flow.

Continuous monitoring of oxygen saturation helps in assessing tissue perfusion and detecting hypoxemia early.

D. Placing the client on strict bed rest can increase the risk of thrombosis and impair circulation.

E.Cold can cause vasoconstriction, worsening the pain and sickling process. Warm compresses are more appropriate for promoting comfort and improving circulation.

F. Meperidine (Demerol) is a potent opioid analgesic that can help alleviate severe pain associated with vaso-occlusive crises.

G. The nurse should not restrict oral intake, as hydration is important to prevent dehydration and further sickling.

H. Hydroxyurea is used to prevent vaso-occlusive crises in patients with sickle cell disease but is not typically administered during an acute crisis. This is a medication that reduces the frequency and severity of vaso-occlusive crises by increasing the production of fetal hemoglobin, which prevents sickling.

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A nurse is caring for a school-age child who has heart failure. Which of the following findings should the nurse expect?Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is ["A","B","C","F","H"]

Explanation

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