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 ["A","C","F"]
Explanation
A. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling.
Explanation: Elevating the extremity can help reduce swelling, especially in the initial period after casting.
B. Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold.
Explanation: Applying heat can increase the risk of burns and is not recommended. If the fingers feel cold, it may indicate a circulation issue, and the healthcare provider should be contacted.
C. Keep small toys and sharp objects away from the cast.
Explanation: Keeping small toys and sharp objects away from the cast is important to prevent injury or damage to the cast.
D. Use a padded ruler or another padded object to scratch the skin under the cast if it itches.
Explanation: Inserting objects under the cast can lead to complications, including skin damage or infection. It is advisable not to insert anything into the cast.
E. Use the fingertips to lift the cast while it is drying.
Explanation: Lifting or manipulating the cast during the drying process can compromise its integrity and should be avoided. The cast needs to dry completely to provide proper support and immobilization.
F. Contact the primary health care provider (PHCP) if the child complains of numbness or tingling in the extremity.
Explanation: Numbness or tingling can indicate a circulation problem, and it is important to contact the healthcare provider for further assessment.
Correct Answer is ["C","D","E"]
Explanation
A. Set the water heater at 65.6° C (150° F):
The recommended temperature for a water heater is around 49°C (120°F) to prevent burns. Setting it at 65.6°C (150°F) can lead to scald injuries.
B. Install accordion style gates: Accordion-style gates are not recommended because they can pose a strangulation risk. The safer option is to use gates with vertical or horizontal slats that are spaced closer together.
C. Fit the mattress so that it is snug against the sides of the crib: A snug-fitting mattress prevents gaps where the baby could get trapped or injured.
D. Tie plastic bags in knots before discarding them:
This prevents accidental suffocation or choking hazards that can occur if an infant gets hold of a plastic bag.
E. Serve food in small, non-circular pieces:Serving food in small, non-circular pieces reduces the risk of choking. Infants should be given age-appropriate foods to minimize the risk of choking, and cutting food into small, easy-to-manage pieces is recommended.
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