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 B
Explanation
A. Shows preferences towards foods
Explanation: Showing preferences towards foods, such as liking some tastes more than others, is a normal developmental behavior in infants. It is not typically a cause for concern.
B. Babbles one-syllable sounds
Explanation:
By the age of 7 months, most infants should be engaging in babbling with repetitive consonant-vowel combinations. If an infant is only producing one-syllable sounds at this age, it might be a potential sign of delayed language development. Further evaluation by a healthcare provider, such as a pediatrician or a speech-language pathologist, may be warranted to assess the child's language and communication skills.
C. Uses a unidextrous grasp
Explanation: A unidextrous grasp, where the infant uses one hand to grasp objects, is a typical developmental milestone at this age. Infants typically begin to show a dominant hand preference later in their development.
D. Has a fear of strangers
Explanation: Fear of strangers, often referred to as "stranger anxiety," is a normal developmental stage that typically emerges around 6 to 9 months of age. It is a sign of social and cognitive development and is not generally a cause for concern.
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
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