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
Explanation
A. Contact the assigned emergency room physician to evaluate the need for an advanced airway
Explanation:
Epiglottitis is a medical emergency that can rapidly progress to airway obstruction. The classic signs and symptoms include a high fever, difficulty swallowing, voice hoarseness, inspiratory stridor, and sternal retractions. Immediate intervention may be necessary to secure the airway. Therefore, contacting the emergency room physician to evaluate the need for an advanced airway (such as intubation) is a priority.
B. Administer intravenous corticosteroids
Explanation: While corticosteroids may be used in the management of epiglottitis to reduce airway inflammation, securing the airway is the priority in the acute phase. Corticosteroids would typically be administered after securing the airway.
C. Obtain a throat culture
Explanation: Obtaining a throat culture is not the immediate priority in the case of suspected epiglottitis. Prompt intervention to secure the airway takes precedence over diagnostic tests.
D. Inspect the throat to obtain further data to support the diagnosis
Explanation: Direct visualization of the throat (inspection) may exacerbate the airway obstruction and is not recommended in the acute management of suspected epiglottitis. The priority is to secure the airway while minimizing agitation and discomfort for the child. Diagnostic procedures, such as obtaining a throat culture, can be considered after the airway is stabilized.
Correct Answer is ["A","B","E"]
Explanation
A."The manifestations are lessened by taking the prednisone every other day instead of daily."
Explanation: Cushingoid characteristics can be related to prolonged corticosteroid use. Adjusting the dosing schedule, such as administering prednisone every other day instead of daily, may help minimize these manifestations.
B."You need to be sure to talk to the doctor about the Cushingoid characteristics."
Explanation: Open communication with the healthcare provider is crucial. Discussing the concerns about Cushingoid characteristics with the doctor allows for appropriate evaluation and potential adjustments to the treatment plan.
C."Which manifestations of this condition do you find most troublesome?"
Explanation: This question opens the discussion to identify specific concerns and allows the nurse to address them individually.
D."I am sure it will be all right; they hardly look unusual."
Explanation: This statement may downplay the parents' concerns. It's essential to acknowledge their worries and provide accurate information about the potential impact of corticosteroids and the plan for managing Cushingoid characteristics.
E."The Cushingoid appearance will gradually disappear once the corticosteroids are tapered and discontinued."
Explanation: Cushingoid characteristics are associated with the side effects of corticosteroid use. The nurse should provide reassurance that, in many cases, these characteristics can gradually improve once the corticosteroid dose is tapered and eventually discontinued.
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