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 ["C","D","E"]
Explanation
A. Pertussis, or whooping cough, primarily affects the respiratory tract, particularly the trachea and bronchi, not just the nostrils.
B. Pertussis is caused by the bacterium Bordetella pertussis, making this statement incorrect as the infection is bacterial, not viral.
C. The toxins released by Bordetella pertussis damage the cilia of epithelial cells in the respiratory tract, leading to difficulty in clearing secretions.
D. The inflammation of the lungs and airways is a characteristic response to the infection, contributing to the symptoms of coughing and difficulty breathing.
E. The production of thick, mucus secretions is a hallmark of pertussis, which makes it challenging for the child to expel them, leading to severe coughing fits.
Correct Answer is ["A","C","D","E"]
Explanation
A. The parent applying prescribed medication as instructed indicates proper understanding of post-operative care and adherence to treatment.
B. Allowing the child to lift their older sibling above the ground is inappropriate as it can lead to increased pressure on the ear, risking complications.
C. Enforcing nose blowing only when necessary is a correct action since excessive force can displace the tympanoplasty tube or introduce bacteria into the ear.
D. Planning to have the child use ear plugs in the shower is an effective precaution to protect the ears from water exposure, which is essential post-surgery.
E. Reporting purulent drainage immediately to the surgeon shows awareness of potential complications and the need for prompt medical attention.