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
B. The FLACC (Face, Legs, Activity, Cry, Consolability) scale is used to assess pain in infants and young children who may not be able to verbalize their pain. Each category is scored from 0 to 2, with a total score ranging from 0 to 10.
A. This scale uses facial expressions to depict pain levels and is typically used for children over 3 years old who can point to the face that represents their pain level.
C. Oucher is used for children who can communicate their pain by pointing to photographs of other children in pain. It is not suitable for infants.
D. Visual Analog Scale requires clients to mark their pain level on a line. It is not suitable for infants who cannot communicate their pain verbally or through such methods.
Correct Answer is A
Explanation
A. Scoliosis is a lateral curvature of the spine, which is characterized by an abnormal sideways curvature of the spine. Scoliosis may be idiopathic (of unknown cause) or secondary to other conditions.
B. Kyphosis is an excessive outward curvature of the spine, causing a rounded or hunched back. It is commonly associated with poor posture or structural abnormalities of the spine
C. Torticollis (wry neck) is characterized by a twisted or tilted neck posture due to muscle spasm or congenital muscular torticollis.
D. Lordosis is an excessive inward curvature of the spine, commonly observed in the lumbar (lower back) or cervical (neck) regions. It may occur as a normal variant or be associated with conditions such as muscle imbalances.
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