A 2-year-old is brought to the emergency department (ED) with a history of several days of rhinitis and now exhibits a productive barking cough and difficulty breathing. Which additional finding should alert the nurse that the child is experiencing respiratory distress?
A resting respiratory rate of 35 breaths/minute.
Flaring of the nares.
Diaphragmatic respirations.
Bilateral bronchial breath sounds.
The Correct Answer is B
A. A respiratory rate of 35 breaths/minute can be normal for a 2-year-old, so it is not necessarily indicative of distress by itself.
B. Flaring of the nares is a sign of increased work of breathing and is an indication of respiratory distress, as the child is using accessory muscles to breathe.
C. Diaphragmatic respirations are typical for young children and not indicative of distress unless other signs are present.
D. Bilateral bronchial breath sounds do not necessarily indicate respiratory distress and could be normal depending on the context.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
A. Serum potassium within the reference range is not typically a cause for concern in this scenario.
B. A hemoglobin A1C level of 7% indicates poor glycemic control and may suggest the need for adjustment in diabetes management, as it exceeds the recommended target range.
C. Total cholesterol within the reference range is not the most significant finding to report in this scenario.
D. Hematocrit within the reference range is not the most significant finding to report in this scenario.
E. A random plasma glucose level of 200 mg/dl (11.1 mmol/L) is indicative of hyperglycemia and requires attention as it suggests poor glycemic control, potentially related to diabetes.
Correct Answer is A
Explanation
A. A right foot that is pale with sluggish capillary refill suggests compromised circulation, possibly due to compartment syndrome, and requires immediate intervention to prevent tissue damage.
B. Circumferential edema of the right foot may be expected after a fracture and casting but does not indicate an immediate complication requiring intervention.
C. Reports of throbbing right leg pain are common after a fracture and casting and may be managed with appropriate pain medication but do not necessarily indicate an immediate complication.
D. An increased temperature to the lower extremity may be indicative of inflammation but does not necessarily require immediate intervention unless accompanied by other signs of infection or complications.
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