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 D
Explanation
A. When a parent is holding the infant
Explanation: Being held by a parent is generally a comforting and calming experience for an infant, and it is unlikely to significantly increase oxygen demand. In fact, the presence of a familiar caregiver may help reduce stress.
B. During sleep
Explanation: During sleep, an infant's oxygen demand may decrease, and oxygen supplementation may not be necessary unless there are specific indications or concerns about oxygen saturation levels.
C. When changing the infant's diapers
Explanation: Changing a diaper is a routine care activity that is not likely to significantly increase oxygen demand. It is not typically associated with stress or increased metabolic activity that would necessitate additional oxygen.
D. When drawing blood for electrolyte level testing
Explanation:
Drawing blood for electrolyte level testing is a potentially stressful procedure that may cause distress and anxiety in the infant. Stress and anxiety can increase the metabolic rate and oxygen demand. In a situation where an infant is already prescribed oxygen as needed for heart failure, additional stressors like blood drawing may necessitate the administration of oxygen to ensure an adequate oxygen supply
Correct Answer is C
Explanation
A. "Range-of-motion exercises must be performed every day."
Explanation: While range-of-motion exercises are important for maintaining joint flexibility in juvenile idiopathic arthritis, it is not advisable to perform these exercises during painful exacerbations. The frequency and intensity of exercises may need to be adjusted based on the child's current condition.
B. "Administer additional pain medication before performing range-of-motion exercises."
Explanation: While pain management is important in the care of a child with juvenile idiopathic arthritis, relying solely on pain medication before exercises may not be the most effective approach. Isometric exercises that are less likely to cause pain can be a better option during exacerbations.
C. "Have the child perform simple isometric exercises during this time."
Explanation:
During a painful exacerbation of juvenile idiopathic arthritis, it is important to maintain joint flexibility and prevent joint contractures. Simple isometric exercises that do not involve joint movement can help in maintaining muscle strength and joint flexibility without exacerbating pain. Range-of-motion exercises may be too painful during an exacerbation, but isometric exercises can be less painful and still beneficial.
D. "Avoid all exercise during painful periods."
Explanation: Complete avoidance of exercise during painful periods is not recommended. Maintaining joint flexibility and muscle strength is important for managing juvenile idiopathic arthritis. However, the type and intensity of exercises should be adjusted based on the child's pain level during exacerbations.
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