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 C
Explanation
A. The frequency of peak flow monitoring should be determined by the healthcare provider and vary depending on the severity of the asthma.
B. Encouraging physical activity is important for overall health, including for children with asthma. Specific sports depend on triggers
C. Identifying and avoiding triggers that can exacerbate asthma symptoms is an essential part of asthma management. By avoiding triggers whenever possible, the child can help prevent asthma attacks and maintain better control of their condition.
D. Cromolyn sodium is a mast cell stabilizer that can help prevent asthma symptoms when used regularly, but it is not typically used for immediate relief of symptoms at the first sign of breathing difficulty. Short-acting bronchodilators, such as albuterol, are usually recommended for quick relief of asthma symptoms.
Correct Answer is A
Explanation
Children with CF often have pancreatic insufficiency, leading to malabsorption of nutrients. Pancreatic enzymes help digest fats, proteins, and carbohydrates, allowing for better absorption of nutrients from food.
B. This response is not specifically related to the nutritional management of CF. While individuals with CF may have increased salt loss through sweat and may need to consume more salt to maintain electrolyte balance, restricting salt is not typically part of CF nutrition management.
C. Hydration is important for individuals with CF to help maintain normal mucus consistency and prevent dehydration, especially during times of increased respiratory secretions.
D. Children with CF often have increased energy needs due to the increased work of breathing and malabsorption of nutrients. Therefore, it is important to provide a diet that is high in calories and nutrient-dense.
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