The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart disease. Which of these is most likely to be seen with this diagnosis?

Correct Answer: C

Rationale: Fatigue and rest needs reflect reduced cardiac output in CHD.

Correct Answer: C

Rationale: An overhead trapeze bar facilitates self-movement for bedridden patients by allowing them to lift or shift their position using upper body strength, reducing dependence on staff and preventing complications like pressure ulcers or muscle atrophy. Aesthetic enhancement is irrelevant it's a functional tool, not decor. Social interaction isn't its purpose, though it might indirectly boost morale. Keeping the room organized doesn't apply; it's about patient mobility. Nurses encourage its use to promote autonomy and physical activity, enhancing recovery and comfort within the constraints of bed rest.

Correct Answer: D

Rationale: Supporting the abdomen with a folded towel or hands helps a bedridden patient cough effectively by stabilizing surgical sites or weak muscles, reducing pain, and boosting force to clear airways. This is vital for preventing pneumonia in immobile patients. A pillow to hug might comfort but doesn't aid cough mechanics. Discouraging coughing risks mucus buildup, worsening respiratory health. Ice water might soothe but doesn't enhance coughing. Nurses use this support to facilitate airway clearance, combining physical assistance with encouragement for optimal respiratory function.

Correct Answer: C

Rationale: Offering thin liquids facilitates swallowing for dysphagia patients by reducing the effort needed to move fluid through the throat, though thickness may vary per assessment (e.g., thickened liquids for some). Large portions overwhelm, increasing choking risk. Variety stimulates taste but doesn't address swallowing mechanics. Rapid eating heightens aspiration danger, fatiguing the patient further. Nurses tailor fluid consistency and pace to the patient's swallow ability, often collaborating with speech therapists, ensuring safe nutrition and hydration critical for this condition.

Correct Answer: C

Rationale: Using therapeutic communication and active listening promotes comfort in an anxious patient by validating their feelings, reducing isolation, and building trust through empathetic dialogue. Leaving them alone may worsen anxiety, signaling abandonment. Avoiding eye contact disconnects, heightening distress. Suggesting no deep breathing dismisses a proven calming technique nurses often encourage it. This approach, involving open-ended questions and reassurance, addresses emotional needs, helping patients cope, a vital nursing skill in holistic care beyond physical interventions.