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 D
Explanation
The correct answer is Choice D: Jaundice.
Choice A rationale:
Vomiting can occur in biliary atresia due to the blockage of bile flow, but it is not the earliest clinical manifestation. Jaundice tends to precede vomiting and is a more characteristic early sign of biliary atresia.
Choice B rationale:
Hepatomegaly (enlargement of the liver) is a common finding in biliary atresia, but it usually occurs after the onset of jaundice. Jaundice is an earlier and more specific manifestation of this condition.
Choice C rationale:
Absence of stooling is a sign that might occur in biliary atresia due to the obstructed bile flow, but it is not typically the earliest clinical manifestation. Jaundice is generally the first noticeable sign.
Choice D rationale:
Jaundice is the earliest clinical manifestation of biliary atresia. It is caused by the buildup of bilirubin in the blood due to impaired bile flow from the liver. The jaundice in biliary atresia is typically progressive and can be one of the key indicators for further evaluation and diagnosis.
Correct Answer is D
Explanation
The correct answer is choice D: Verbalizing the importance of monitoring for medication side effects.
Choice A rationale:
Allowing the adolescent to make decisions about whether or not to take medication is important, but it is not the priority nursing goal for a 14-year-old diagnosed with Graves' disease. The priority is ensuring proper medication management and monitoring to control the thyroid dysfunction and prevent potential complications.
Choice B rationale:
Relieving constipation might be a consideration, but it is not the priority nursing goal for a 14-year-old diagnosed with Graves' disease. The primary focus is on addressing the thyroid-related issues and providing appropriate education and support to the adolescent.
Choice C rationale:
Developing alternative educational goals is not the priority nursing goal for a 14-year-old diagnosed with Graves' disease. While education is important, the immediate concern is managing the medical condition and ensuring the adolescent's well-being.
Choice D rationale:
Verbalizing the importance of monitoring for medication side effects is the priority nursing goal for a 14-year-old diagnosed with Graves' disease. Graves' disease is a thyroid disorder that requires medication management, typically involving antithyroid medications or other interventions. Monitoring for medication side effects ensures the adolescent's safety and helps to prevent adverse reactions or complications. It also empowers the adolescent to be vigilant about their health and medication regimen.
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