A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect?
Bradycardia
Weight loss
Orthopnea
Increased urine output
The Correct Answer is C
A. Bradycardia is not typically expected in toddlers with heart failure; instead, tachycardia (increased heart rate) is more common as the body compensates for decreased cardiac output.
B. Weight loss is generally not a typical finding in toddlers with heart failure; rather, they often experience weight gain due to fluid retention.
C. Orthopnea, or difficulty breathing when lying flat, is a common symptom of heart failure and would be expected in a toddler due to fluid overload affecting respiratory function.
D. Increased urine output is usually not expected in heart failure; rather, fluid retention often leads to decreased urine output as the kidneys respond to the body's fluid balance needs.
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Correct Answer is ["A","B","D","E"]
Explanation
A. It is important for the client to remain in bed for a specified time (typically 4 to 6 hours) to prevent complications such as bleeding at the catheter insertion site.
B. Checking peripheral pulses in the affected extremity is crucial for assessing circulation and identifying any potential complications, such as hematoma or occlusion.
C. High-Fowler's position is not typically appropriate immediately after cardiac catheterization; the client should remain flat or with limited elevation to reduce stress on the insertion site.
D. Keeping the hip and leg extended is important to prevent flexion at the site of catheter insertion, reducing the risk of bleeding or hematoma formation.
E. Measuring vital signs is essential after a procedure like cardiac catheterization to monitor for any changes that may indicate complications; however, the frequency is typically more frequent than every 4 hours initially.
Correct Answer is A
Explanation
A. Distributive shock, particularly in the context of anaphylaxis, is characterized by widespread vasodilation that leads to a decrease in systemic vascular resistance and impaired blood flow to organs despite normal or increased cardiac output.
B. This option is incorrect because distributive shock involves decreased systemic vascular resistance due to vasodilation rather than an increase.
C. This statement describes hypovolemic shock, not distributive shock. Distributive shock is not primarily caused by the loss of blood volume.
D. While loss of myocardial contractility can lead to cardiogenic shock, it is not the mechanism behind distributive shock, which is related to vascular tone rather than heart function.