Health Promotion and Maintenance
58. A nurse is caring for a child newly diagnosed with congenital heart disease. The nurse should monitor the child with the understanding that the earliest sign of heart failure is:
Health Promotion and Maintenance
58. A nurse is caring for a child newly diagnosed with congenital heart disease. The nurse should monitor the child with the understanding that the earliest sign of heart failure is:
Test-Taking Tip
Note how three of the answers are similar in that they describe fluid retained in the wrong area. Only one answer is an effort to prevent fluid retention, and is therefore the earliest sign of failure.
Content Area: Child Health, Cardiovascular; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Health Promotion and Maintenance
.
Answer 1 is incorrect because lung crackles indicate fluid in the lungs, which occurs after the increase in heart rate is no longer effective in compensating for poor cardiac functioning. Answer 2 is correct because the body tries to compensate for a failing heart by first increasing the heart rate as a way to increase circulating blood volume. Answer 3 is incorrect because weight gain occurs more slowly over time as the kidneys attempt to retain fluid in response to the poor cardiac output. Answer 4 is incorrect because generalized edema occurs more slowly over time as the kidneys attempt to retain fluid in response to the poor cardiac output.
