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 C
Explanation
The correct answer is choice C.
Choice C rationale:
Placing the avulsed tooth in cold milk is the most suitable medium for transporting it to the dentist. Cold milk helps preserve the viability of the tooth's cells and tissues, which is crucial for successful reimplantation. The temperature and composition of cold milk provide a suitable environment to prevent cell damage.
Choice A rationale:
Placing the tooth in a dry, clean jar is not recommended. A dry environment can cause the tooth's cells to dry out and become nonviable, making reimplantation less successful.
Choice B rationale:
Warm salt water is not the optimal choice for transporting an avulsed tooth. Warm water can cause damage to the tooth's cells, and salt water may not provide the necessary conditions to maintain the tooth's viability.
Choice D rationale:
Placing the tooth in cold water might seem logical, but it is not as effective as cold milk. Cold water lacks the protective properties and nutrients that milk provides, potentially leading to a higher risk of cell damage in the avulsed tooth.
Correct Answer is D
Explanation
Answer is: d. Apply direct pressure above the catheterization site.
Explanation: The first action should be to apply direct pressure above the catheterization site to help control the bleeding and minimize blood loss. This will also give the nurse time to prepare additional interventions or supplies if necessary.
Choice a. is wrong because placing the child in the Trendelenburg position is not an appropriate initial nursing action in this scenario. This position can increase intracranial pressure and is typically used for patients experiencing shock or hypotension.
Choice b. is wrong because applying a new bandage with more pressure might be a subsequent action, but the priority is to apply direct pressure to slow down the bleeding.
Choice c. is wrong because notifying the physician is important, but the nurse should first take immediate action to control the bleeding and minimize potential harm to the patient.
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