A nurse is caring for a 5-year-old child in the acute care setting.

exhibits

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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.

Answer and Explanation

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

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Correct Answer is D

Explanation

A child with nephrotic syndrome is not infectious and therefore, does not pose a significant risk of infection to the child

A child recovering from a ruptured appendix may still carry an infection posing a risk of life threatening infection to the child with leukemia.

Although rheumatic fever occurs several days after the active streptococcal infection starts, a child with rheumatic fever still poses a risk of infection to the child with leukemia.

A. Admit the client to a private room. B. Measure head circumference every shift. C. Implement seizure precautions. D. Place the client in a semi-Fowler's position.

Correct Answer is B

Explanation

A. Admitting the client is necessary to prevent the spread of infection and provide a controlled environment for the child.
B. Measuring the head circumference is not typically necessary for bacterial meningitis as the sutures are closed raised intracranial pressure does not affect circumference.
C. Seizures can be a complication of bacterial meningitis, so this intervention is important to ensure the child's safety.
D. The semi-Fowler’s position helps to decrease ICP and facilitate breathing, which is crucial in the care of a child with bacterial meningitis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child?

Correct Answer is D

Explanation

A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care?

Correct Answer is B

Explanation

A nurse is teaching about neural tube defects to a group of females who are pregnant. Which of the following disease processes should the nurse include as an example of a neural tube defect?

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A nurse is teaching a parent of an infant who has heart failure about meeting the infant's nutritional needs. Which of the following statements by the parent indicates an understanding of the teaching?

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