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.)

The correct answer is choice A: Signs of stress.

Choice A rationale:

Children often express stress through physical complaints such as stomach pains, headaches, and fatigue. The 9-year-old's complaints of stomach pains, along with the description of aggressive and stubborn behavior, are indicative of stress. Stressors can include academic pressures, family issues, social challenges, or other emotional factors.

Choice B rationale:

Developmental delay refers to a situation where a child's developmental milestones are significantly delayed compared to their peers. This doesn't align with the presented symptoms of stomach pains, aggression, and stubbornness. These symptoms are more indicative of emotional or psychological distress.

Choice C rationale:

While a physical problem could potentially cause emotional stress, the scenario doesn't provide enough information to directly conclude that a physical problem is the primary trigger. Stomach pains could indeed result from emotional stress, and it's important to consider the child's overall well-being.

Choice D rationale:

Lack of adjustment to the school environment can lead to behavioral and emotional challenges, but it's not the most direct explanation for the symptoms described in the scenario. The combination of stomach pains and behavioral changes suggests a more immediate emotional trigger, which is often stress-related.

The correct answer is choice C. Activity intolerance related to generalized weakness.

Choice A rationale:

Risk for injury related to depressed sensorium. This choice is not the most appropriate nursing diagnosis for a child with moderate anemia. While anemia can lead to fatigue and weakness, the main concern is the child's ability to tolerate physical activities, not the risk of injury due to a depressed sensorium.

Choice B rationale:

Decreased cardiac output related to abnormal hemoglobin. This choice is not the most suitable nursing diagnosis for a child with moderate anemia. While abnormal hemoglobin levels can affect cardiac output, moderate anemia typically doesn't lead to such a significant decrease in cardiac output that it becomes the primary nursing diagnosis. Activity intolerance is a more relevant concern.

Choice C rationale:

Activity intolerance related to generalized weakness. This is the most appropriate nursing diagnosis for a child diagnosed with moderate anemia. Moderate anemia results in a decrease in oxygen-carrying capacity, leading to generalized weakness and reduced ability to perform physical activities without becoming fatigued. The child's hemoglobin levels are likely low enough to cause noticeable activity intolerance.

Choice D rationale:

Risk for Injury related to dehydration and abnormal hemoglobin. This choice is not the best nursing diagnosis for a child with moderate anemia. Dehydration may exacerbate the effects of anemia, but the primary issue here is the anemia itself causing weakness and activity intolerance, which are better addressed with the choice C diagnosis.