Which assessment findings would alert the nurse to an infant or child in heart failure? (Select All that Apply.)
Tachypnea
Wheezes or rales
Bounding pulses
Edematous
Difficulty feeding
Increased comfort laying down
Correct Answer : A,B,D,E
A. Tachypnea. Rapid breathing can indicate respiratory distress associated with heart failure.
B. Wheezes or rales. These are abnormal breath sounds indicating fluid in the lungs, which can occur with heart failure.
C. Bounding pulses. Bounding pulses are not typically associated with heart failure; weak pulses may be present due to poor perfusion.
D. Edematous. Edema can occur due to fluid retention, a sign of heart failure.
E. Difficulty feeding. Poor feeding can result from decreased cardiac output affecting systemic circulation and energy for feeding.
F. Increased comfort laying down. Children with heart failure often prefer sitting upright due to respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Oversupply of milk. This can lead to milk stasis and blockage, which can increase the risk of mastitis.
B. Gradual weaning of breastfeeding. Gradual weaning typically helps reduce the risk of mastitis because it allows the milk supply to decrease slowly and naturally without engorgement or blockage.
C. Infrequent, inconsistent feedings. This can lead to milk stasis and is a common cause of mastitis.
D. Cracks or fissures of the nipples. These can provide an entry point for bacteria, leading to infection and mastitis.
Correct Answer is ["A","B","D","E"]
Explanation
A. Tachypnea. Rapid breathing can indicate respiratory distress associated with heart failure.
B. Wheezes or rales. These are abnormal breath sounds indicating fluid in the lungs, which can occur with heart failure.
C. Bounding pulses. Bounding pulses are not typically associated with heart failure; weak pulses may be present due to poor perfusion.
D. Edematous. Edema can occur due to fluid retention, a sign of heart failure.
E. Difficulty feeding. Poor feeding can result from decreased cardiac output affecting systemic circulation and energy for feeding.
F. Increased comfort laying down. Children with heart failure often prefer sitting upright due to respiratory distress.
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