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 D
Explanation
A. Encouraging excessive rest and avoidance of physical activities can lead to feelings of inferiority by limiting opportunities for achievement and social interactions.
B. Limiting social interactions is counterproductive, as friendships and peer relationships are critical for social development during this stage.
C. While supervision is important, overly controlling the child’s activities can inhibit their ability to explore and learn, negatively impacting their sense of industry.
D. Involving the child in decision-making and providing opportunities for independent tasks fosters a sense of competence and accomplishment, essential for developing a sense of industry, according to Erikson’s theory.
Correct Answer is B
Explanation
A. Administering IV fluids may be necessary but is not the first priority in managing a suspected airway emergency.
B. Placing the child on droplet precautions is the first action to take to prevent the spread of infection and protect healthcare workers, given the suspected diagnosis of epiglottitis.
C. Initiating IV antibiotics is essential but should follow ensuring that appropriate precautions and assessments are in place.
D. While obtaining an x-ray can confirm the diagnosis, the child's safety and airway management must be prioritized first to avoid potential respiratory distress.