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 A
Explanation
A. Dysmenorrhea that is unresponsive to NSAIDs. Endometriosis often causes severe pelvic pain that does not improve with NSAIDs, distinguishing it from typical menstrual cramps.
B. A history of pelvic inflammatory disease (PID). PID is not directly associated with endometriosis and typically presents differently.
C. Abdominal bloating starting several days before menses. While bloating can occur with endometriosis, it is not a definitive symptom for diagnosis.
D. An atypical Papanicolaou smear at her last clinic visit. An atypical Pap smear is more related to cervical abnormalities, not endometriosis.
Correct Answer is ["A","C","D"]
Explanation
A. Fetal breathing. The biophysical profile assesses fetal breathing movements as one of the components indicating fetal well-being.
B. Fetal neck translucency. This is not part of the biophysical profile; it is typically assessed during first-trimester screening for chromosomal abnormalities.
C. Fetal motion. Fetal movements are another component of the biophysical profile, reflecting the fetal central nervous system integrity and oxygenation.
D. Amniotic fluid volume. The assessment of amniotic fluid volume is crucial in determining fetal well-being and adequate fetal renal function.
E. Fetal gender. Gender is not assessed as part of the biophysical profile; the test focuses on fetal physiological parameters related to well-being.
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