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. Thick yellow crusted lesion on a red base are characteristic of impetigo.
B. Pediculosis capitis (head lice infestation) presents with itching and scratching of the head due to the allergic reaction to the saliva of the lice. While other conditions may present with similar symptoms, itching and scratching are classic signs of head lice infestation.
C. Firmly attached white particles on the hair are indicative of nits (lice eggs).
D. Patchy areas of hair loss may be seen in conditions like alopecia areata or fungal infections but are not specific to pediculosis capitis.
Correct Answer is B
Explanation
Red marks across the cheeks can be indicative of various conditions, including skin irritation, allergies, or infections. Before jumping to conclusions or taking further actions, the nurse should conduct a thorough assessment of the child's overall condition. Assessing the rest of the child's body for any additional signs or symptoms, such as a rash or other skin abnormalities, can provide more information about the cause of the red marks on the cheeks. Depending on the findings of the assessment, further action may be necessary, such as questioning the parents about potential causes or referring the family to appropriate services if there are concerns about the child's well-being. However, the initial step should be to assess the child's condition comprehensively.
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