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 D

Explanation

A. "Right now, I can't bathe or dress myself, but my family will help me." Dependence on family for basic self-care suggests the client is not yet independent enough for discharge.

B. "I can always come stay in the hospital again if I don't want to take care of my own needs." This statement shows a lack of commitment to self-care and reliance on hospitalization as a coping mechanism.

C. "Taking care of myself is important, but it's okay if I don't want to do anything." Readiness for discharge includes a commitment to self-care, and this statement suggests a lack of motivation.

D. "I will take my medicines as I should and know who to call if I have bad thoughts." This statement shows insight into the importance of medication adherence and knowledge of available support resources, indicating readiness for discharge.

A. 5th Intercostal Space, Midclavicular Line B. 2nd Intercostal Space, Left Sternal Border C. 2nd Intercostal Space, Right Sternal Border D. 3rd Intercostal Space, Left Sternal Border

Correct Answer is C

Explanation

A. 5th Intercostal Space, Midclavicular Line. This is the location for the apical pulse (PMI) at the mitral area, not the aortic valve.

B. 2nd Intercostal Space, Left Sternal Border. This is the location of the pulmonic valve, not the aortic valve.

C. 2nd Intercostal Space, Right Sternal Border. The aortic valve is best auscultated at the right second intercostal space, next to the sternum.

D. 3rd Intercostal Space, Left Sternal Border. This is the Erb’s point, which provides equal S1 and S2 sounds, but it is not the best location for auscultating aortic valve dysfunction.

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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 assisting in the care of a client who has a mood disorder. Which of the following client statements by the client indicates readiness for discharge?

Correct Answer is D

Explanation

The nurse is planning to auscultate heart sounds. The history and physical indicates a history of Aortic Valve dysfunction. Where would the nurse auscultate to assess the Aortic Valve?

Correct Answer is C

Explanation

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