A nurse is caring for a 5-year-old child in the acute care setting.
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Child remains in bed. Child uncooperative and agitated, Refusing PO fluids. Child reports chest pain and joint pain as a 4 on the Faces Scale. Nasal flaring and moderate subcostal and substernal retractions are noted. Bilateral, moderate inspiratory and expiratory wheezes noted upon auscultation. Voided 200 mL of clear yellow urine
Child reports chest pain and joint pain as a 4 on the Faces Scale.
Nasal flaring and moderate subcostal and substernal retractions are noted.
Bilateral
moderate inspiratory and expiratory wheezes noted upon auscultation.
The Correct Answer is ["A","B","C","D"]
These findings indicate that the child is experiencing significant pain, which is concerning, especially considering the history of sickle cell anemia and the recent increase in pain despite previous management with acetaminophen. Chest pain could also be indicative of a vaso-occlusive crisis or a respiratory complication.
Nasal flaring and moderate subcostal and substernal retractions are noted:
Nasal flaring and retractions suggest increased work of breathing, which could indicate respiratory distress. In a child with sickle cell anemia, respiratory complications like acute chest syndrome are a significant concern during a vaso-occlusive crisis.
Bilateral, moderate inspiratory and expiratory wheezes noted upon auscultation:
Wheezing indicates airway obstruction or inflammation, which could be due to asthma exacerbation, infection, or acute chest syndrome, all of which are common complications in children with sickle cell disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Booster seats are used for older children who have outgrown their forward-facing car seats. A 24- month-old toddler is typically too young and small for a booster seat.
B. Rear-facing car seats provide the best protection for young children, including toddlers, in the event of a crash.
B. The American Academy of Pediatrics (AAP) recommends keeping children in a rear-facing car seat until they reach the maximum height or weight limit. Rear-facing seats distribute crash forces more evenly across the back of the car seat and the child's body, reducing the risk of injury to the head, neck, and spine.
C. Placing a car seat forward-facing in the front passenger side and inactivating the airbag is not recommended for any child under the age of 13 due to the risk of injury from the airbag in the event of a crash.
D. Placing a car seat rear-facing in the front passenger side is not recommended, especially for a toddler.
Correct Answer is B
Explanation
A. The calorie needs of toddlers vary depending on factors such as age, weight, height, activity level, and metabolism. 3,000 calories per day is likely to be excessive for most toddlers.
B. Although calorie intake is important for growth and development, the emphasis should be on the nutritional quality of the foods rather than solely on the quantity of calories consumed. Providing nutrient-rich foods ensures that the toddler receives essential vitamins, minerals, and other nutrients necessary for growth and development.
C. Vitamin supplementation may be necessary for some toddlers but it should be done under the guidance of a healthcare provider to ensure appropriate dosing and to avoid potential overdose or adverse effects.
D. An increased appetite alone does not guarantee adequate nutrition if the quality of the foods consumed is poor.
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