The nurse is collecting data on a 2 month-old-child with left-sided congestive heart failure. Which clinical manifestation would support this diagnosis of left-sided congestive heart failure?
Edema in the lower extremities
Ascites
Shortness of breath
Hepatomegaly
The Correct Answer is C
A. Edema in the lower extremities:
Incorrect: Edema in the lower extremities is more characteristic of right-sided heart failure. In left-sided failure, pulmonary congestion is more prominent.
B. Ascites:
Incorrect: Ascites, or fluid accumulation in the abdominal cavity, is also more commonly associated with right-sided heart failure.
C. Shortness of breath:
Correct Answer: Left-sided congestive heart failure can lead to pulmonary congestion, resulting in difficulty breathing or shortness of breath. This is often observed as increased work of breathing, rapid breathing, or other signs of respiratory distress in infants.
D. Hepatomegaly:
Incorrect: Hepatomegaly, or enlargement of the liver, is another manifestation more commonly associated with right-sided heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Crayons and a coloring book:
Incorrect: Crayons and coloring books may not be appropriate for a 12-month-old, as they may pose a choking hazard. Additionally, they might require more direct contact, which may not be ideal under contact precautions.
B. Modeling clay:
Incorrect: Modeling clay may also pose a choking hazard for a toddler. Moreover, it can be messy and may not be suitable for use in a hospital room with contact precautions.
C. Hanging crib toys.
Correct Answer: Hanging crib toys can provide visual and tactile stimulation for the toddler without the need for direct contact. These toys can be attached to the crib, allowing the child to engage with them safely.
D. Large building blocks:
Incorrect: While large building blocks can be suitable for a toddler's developmental needs, they may not be the best option in a confined hospital room under contact precautions. The child's access to and handling of the blocks may be limited in this setting.
Correct Answer is C
Explanation
A. Meningococcal polysaccharide vaccine
Explanation: Meningococcal vaccine is recommended for adolescents, particularly before starting college, as it helps protect against meningococcal disease. The conjugate form of the vaccine is usually preferred over the polysaccharide form.
B. Pneumococcal polysaccharide vaccine
Explanation: Pneumococcal vaccine is generally recommended for older adults and individuals with specific medical conditions, but it may not be part of routine immunizations for healthy adolescents.
C. Influenza vaccine
Explanation:
Influenza vaccine is recommended annually for adolescents as part of routine immunizations. It helps protect against the seasonal flu, which can cause significant illness and complications.
D. Bacille Calmette-Guerin (BCG) vaccine
Explanation: BCG vaccine is primarily used in some countries to prevent tuberculosis. It is not routinely administered in the United States as part of standard immunization schedules for adolescents.
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