A child is being evaluated for increased work of breathing. While inspecting the child's chest, the nurse notes pulling in or sucking in of the skin between the child's ribs. How might the nurse accurately document this finding?

Nasal flaring present.

Suprasternal retractions present.

Intercostal retractions present.

Subcostal retractions present.

Answer and Explanation

The Correct Answer is C

A. Nasal flaring present. Nasal flaring is a separate sign of respiratory distress, but it does not describe retractions.

B. Suprasternal retractions present. Suprasternal retractions occur above the sternum, not between the ribs.

C. Intercostal retractions present. Intercostal retractions occur between the ribs and indicate difficulty breathing due to increased respiratory effort.

D. Subcostal retractions present. Subcostal retractions occur below the ribcage, not between the ribs.

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Correct Answer is A

Explanation

A. Identify when the client first noticed the lesion. Determining onset and duration helps assess whether the lesion is new, growing, or concerning for malignancy.

B. Photograph the lesion for the client's medical record. While documentation is important, assessing history and changes in the lesion takes priority.

C. Instructing the client on the use of daily sunscreen products. Sunscreen is essential for prevention, but identifying and assessing the lesion comes first.

D. Document the client's history of skin allergies. While important, it does not take priority over determining how long the lesion has been present and whether it is changing.

A. FACES B. FLACC C. Visual Analog Scale D. Oucher

Correct Answer is B

Explanation

A. FACES. The Wong-Baker FACES scale is used for children aged 3 years and older who can understand and select a face representing their pain level.

B. FLACC. The FLACC scale (Face, Legs, Activity, Cry, Consolability) is used for infants and nonverbal children to assess pain through observation of behaviors.

C. Visual Analog Scale. The Visual Analog Scale (VAS) requires the client to point on a numeric pain scale, which is inappropriate for infants who cannot communicate pain verbally.

D. Oucher. The Oucher scale is similar to FACES and is used in children aged 3–12 years. It relies on self-report, which is not feasible for a 6-month-old infant.

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A child is being evaluated for increased work of breathing. While inspecting the child's chest, the nurse notes pulling in or sucking in of the skin between the child's ribs. How might the nurse accurately document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who reports finding a new skin lesion. Which of the following actions is the nurse's priority?

Correct Answer is A

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Correct Answer is B

Explanation

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