The nurse is conducting discharge teaching about signs and symptoms of heart failure to parents of an infant with a repaired tetralogy of Fallot. Which signs and symptoms should the nurse include? (Select all that apply.)
Decreased urinary output.
Sweating (inappropriate).
Warm flushed extremities.
Anorexia.
Weight loss.
Correct Answer : A,B,D
The correct answers are choices A, B, and D.
Choice A rationale:
Decreased urinary output can be a sign of heart failure, especially in infants. In heart failure, the heart's ability to pump effectively can lead to decreased blood flow to the kidneys, resulting in decreased urine production.
Choice B rationale:
Sweating (inappropriate) is a symptom of heart failure in infants. Infants with heart failure might sweat excessively, especially while feeding or crying, due to the effort required by the heart to pump blood effectively.
Choice C rationale:
Warm flushed extremities are not typically associated with heart failure in infants. In heart failure, extremities might actually become cool and pale due to poor circulation.
Choice D rationale:
Anorexia, or a lack of appetite, is a common sign in infants with heart failure. The increased effort required for feeding due to compromised cardiac function can lead to poor feeding and decreased appetite.
Choice E rationale:
Weight loss can occur in infants with heart failure due to inadequate caloric intake, difficulty with feeding, and increased metabolic demands associated with heart failure. However, it's not as specific a sign as decreased urinary output, sweating, and anorexia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
The correct answer is choice A, E.
Choice A rationale:
Using an air conditioner is an effective way to reduce exposure to pollens and dust. Air conditioners filter the air and help prevent outdoor allergens from entering the indoor environment. This choice is correct because it addresses one of the primary sources of exposure to allergens.
Choice B rationale:
Keeping humidity in the house above 60% is not a recommended approach. High humidity can promote the growth of mold and dust mites, which can exacerbate allergies. Maintaining humidity levels between 30-50% is generally recommended for reducing allergen exposure.
Choice C rationale:
Keeping pets outside might seem like a logical option to reduce allergen exposure; however, pet allergens can still be carried indoors on clothing and shoes. Moreover, if individuals are not allergic to pet dander, keeping the pets inside may not pose an issue.
Choice D rationale:
Replacing wall-to-wall carpeting with wood and tile floors is a good strategy for reducing allergen exposure. Carpets can trap dust, pollen, and other allergens, while hard surfaces are easier to clean and do not accumulate allergens as readily. This choice is correct because it addresses a common source of indoor allergens.
Choice E rationale:
Putting dust-proof covers on pillows and mattresses is another effective strategy for reducing allergen exposure. These covers create a barrier that prevents dust mites and their allergens from permeating the sleeping environment. This choice is correct because it directly addresses the issue of dust mite allergens.
Correct Answer is C
Explanation
The correct answer is choice C. Explain in simple terms how it works.
Choice A rationale:
Asking the girl why she wants to know might be appropriate in some contexts, but children are naturally curious and seeking information is a common behavior. Explaining how the blood pressure apparatus works would likely be more beneficial than questioning her motivation.
Choice B rationale:
Determining why she is anxious assumes that the girl is anxious, which might not be the case. Additionally, the question she asked does not necessarily indicate anxiety, but rather a curiosity about the medical equipment.
Choice C rationale:
Explaining in simple terms how the blood pressure apparatus works is the most appropriate nursing action. This approach respects the child's curiosity and provides her with age-appropriate information, fostering a positive and educational interaction.
Choice D rationale:
Telling her that she will see how it works as it is used might not fully satisfy her curiosity or address her immediate question. Children often benefit from clear and concise explanations, especially when it comes to medical equipment.
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