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
Explanation
A. A child whose parents consistently answer questions on their behalf may indicate a lack of autonomy and could be a sign of potential abuse or neglect, as it may suggest the parents are controlling or overly involved.
B. A child who has frequent visitors does not inherently suggest abuse; in fact, it could indicate support and care from family or friends.
C. Frequent use of the call light could indicate a child's need for assistance or comfort but does not directly correlate with abuse.
D. A child with a BMI indicating obesity is not a definitive indicator of abuse; it may relate to dietary habits or lifestyle factors rather than abuse.
Correct Answer is A
Explanation
A. Crushed ice is appropriate after a tonsillectomy as it can help soothe the throat and is a clear liquid that is easy for the child to swallow.
B. Cranberry juice is acidic, which can irritate the throat and is generally not recommended immediately after tonsillectomy.
C. Orange juice is also acidic and could cause discomfort to the healing throat tissues, making it unsuitable for post-operative care.
D. A vanilla milkshake may be too thick for the child to swallow comfortably after surgery and can pose a risk of choking.