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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. "The most common manifestation of postpartum depression is harming the infant." This is incorrect; harming the infant is a severe complication but not the most common manifestation.
B. "It's common for clients who have postpartum depression to exhibit psychotic behavior." Psychotic behavior is a rare but serious complication of postpartum depression.
C. "Postpartum depression usually begins 48 hours after childbirth." Postpartum blues may start within this timeframe, but postpartum depression typically manifests later.
D. "Postpartum depression is more likely to occur in women who have a history of depression." This statement correctly identifies a significant risk factor for postpartum depression.

A. A 10-year-old with a burn on the palm of the hand B. A 6-year-old with splash burns on the front torso C. A 4-year-old with circular abrasions around the wrists D. A 2-year-old with a large bruise on the forehead

Correct Answer is C

Explanation

A. A 10-year-old with a burn on the palm of the hand: This could potentially be accidental, for example, from touching a hot surface. However, while it requires further investigation, it is not as strongly indicative of abuse as the given option.
B. A 6-year-old with splash burns on the front torso: These burns could result from accidentally spilling hot liquids. Though it raises concern, it often indicates an accident rather than abuse unless accompanied by other suspicious signs.
C. A 4-year-old with circular abrasions around the wrists: This is highly suspicious of abuse because circular abrasions can indicate that the child may have been tied or restrained, which is not typical of accidents or normal play.
D. A 2-year-old with a large bruise on the forehead: This type of injury is common in young children who are prone to falls and bumps. It might not immediately suggest abuse without additional context.

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Which assessment findings would alert the nurse to an infant or child in heart failure? (Select All that Apply.)

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Naxlex Comprehensive Predictor Exams

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