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Exam NCLEX-RN topic 7 question 58 discussion

Actual exam question from Test Prep's NCLEX-RN
Question #: 58
Topic #: 7
[All NCLEX-RN Questions]

A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are appropriate. Which nursing diagnosis should have priority?

  • A. Altered nutrition: less than body requirements related to inability to take in adequate calories
  • B. Altered growth and development related to decreased intake of food
  • C. Activity intolerance related to imbalance between oxygen supply and demand
  • D. Decreased cardiac output related to ineffective pumping action of the heart
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Suggested Answer: D 🗳️
(A) Altered nutrition occurs owing to the fatigue from decreased cardiac output associated with congestive heart failure. (B) The decreased intake occurs due to fatigue from the altered cardiac output. (C) Fatigue occurs due to the decreased cardiac output. (D) The ineffective action of the myocardium leads to inadequate
O2 to the tissues, which produces activity intolerance, altered nutrition, and altered growth and development.
by [deleted] at March 10, 2025, 7:18 a.m.

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