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
Explanation
A. Heat intolerance
Explanation:
Graves' disease is an autoimmune disorder that results in hyperthyroidism, meaning there is an overproduction of thyroid hormones. Common symptoms of Graves' disease include heat intolerance, increased sweating, weight loss, palpitations, and anxiety. The hyperactivity of the thyroid gland leads to an increased metabolic rate, causing heat intolerance.
B. Bradycardia
Explanation: Bradycardia (slow heart rate) is not typically associated with Graves' disease. Hyperthyroidism usually leads to an increased heart rate (tachycardia) due to the stimulatory effects of thyroid hormones on the cardiovascular system.
C. Lethargy
Explanation: Lethargy (excessive tiredness or lack of energy) is more commonly associated with hypothyroidism, where there is an insufficient production of thyroid hormones. In Graves' disease, the excess thyroid hormones often lead to symptoms of hyperactivity, not lethargy.
D. Weight gain
Explanation: Weight gain is not a typical finding in Graves' disease. Hyperthyroidism often leads to unintentional weight loss due to increased metabolism and energy expenditure. Weight gain is more commonly associated with hypothyroidism.
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