A nurse is assessing a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status? (Select all that apply.)
Oxygen saturation 95%
Warm extremities
Wheezing
Nasal flaring
Retraction of sternal muscles
Correct Answer : C,D,E
Choice A reason: An oxygen saturation of 95% is within the normal range and does not indicate respiratory deterioration.
Choice B reason: Warm extremities are not an indication of respiratory status deterioration; they are generally a sign of good circulation.
Choice C reason: Wheezing is a common sign of airway obstruction in asthma and can indicate a deterioration in respiratory status.
Choice D reason: Nasal flaring is a sign of increased work of breathing and can indicate respiratory distress in a child with asthma.
Choice E reason: Retraction of sternal muscles is a sign of respiratory distress and can indicate a worsening condition in a child with asthma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The FACES scale is not typically used for infants as they cannot verbally express or select a face that correlates with their pain level.
Choice B reason: The Oucher scale requires a child to point to a face that shows how much pain they are feeling, which is not suitable for infants who cannot communicate their pain verbally.
Choice C reason: The FLACC scale is appropriate for infants as it assesses pain based on five categories of behavior: Facial expression, Leg movement, Activity, Cry, and Consolability.
Choice D reason: The Non-communicating children's pain checklist is designed for children with cognitive impairments and is not the best choice for assessing pain in infants.
Correct Answer is B
Explanation
Choice A reason: Removing personal objects from the room is not reflective of palliative care principles, which focus on comfort and personal significance.
Choice B reason: Listening and responding to the family's discussions about their child's life aligns with the holistic approach of palliative care, which includes emotional support.
Choice C reason: Expressing personal feelings of missing the client is not indicative of an understanding of palliative care roles and responsibilities.
Choice D reason: Being hopeful about new medications is not relevant to palliative care, which focuses on quality of life rather than curative treatment.
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