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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Ribbon-like stools
Explanation: Ribbon-like or pencil-thin stools are associated with conditions affecting the rectum, such as colorectal cancer, but they are not a typical sign of intussusception.
B. Profuse projectile vomiting
Explanation: Profuse projectile vomiting is not a typical sign of intussusception. Vomiting may occur, but it is not the primary characteristic feature.
C. Bright red blood and mucus in the stools
Explanation:
Intussusception is a condition in which one part of the intestine slides into another, causing a blockage. One of the classic signs of intussusception is the presence of "currant jelly" stools, which are characterized by a mixture of bright red blood and mucus in the stools. This occurs due to the compression of the blood vessels in the intestine, leading to bleeding and mucosal discharge.
D. Watery diarrhea
Explanation: Watery diarrhea is not a typical sign of intussusception. The condition is more commonly associated with abdominal pain, vomiting, and the characteristic "currant jelly" stools.

A. "Has the child had any difficulty swallowing food?" B. "Does the child play with an imaginary friend?" C. "Does the child respond when called by name? D. "Was the child recently treated for pneumonia?"

Correct Answer is A

Explanation

A. "Has the child had any difficulty swallowing food?"
Explanation:
Cleft palate repair can impact various aspects of a child's development, and one potential long-term effect is difficulty with swallowing or feeding. This question is relevant to assessing the child's oral and feeding function, which can be influenced by the cleft palate repair.
B. "Does the child play with an imaginary friend?"
Explanation: Imaginary play and social interactions are not directly related to the long-term effects of cleft palate repair. This question focuses more on social and imaginative development.
C. "Does the child respond when called by name?"
Explanation: Responsiveness to one's name is a general developmental milestone and is not directly related to the long-term effects of cleft palate repair.
D. "Was the child recently treated for pneumonia?"
Explanation: While respiratory issues can be a concern in children with a history of cleft palate, this question is more specific to recent health issues and does not address the long-term effects of cleft palate repair.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented?

Correct Answer is C

Explanation

A preschooler with a history of cleft palate repair comes to the clinic for a routine well-child checkup. To determine whether this child is experiencing a long-term effect of cleft palate, which question would the nurse ask the parent?

Correct Answer is A

Explanation

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