A nurse is caring for a 5-year-old child in the acute care setting.
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1600
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 D
Explanation
A. 15 angle is for intradermal injection not for intramuscular
B. The needle should be inserted into the middle third of the deltoid muscle, which is typically 2 to 3 finger widths below the acromion process.
C. A smaller gauge needle, such as 22 or 23, is often used for pediatric vaccinations to minimize discomfort. This should, however, be adjusted accordingly based on individual characteristics
D. Ashorter needle length, such as 1.8 mm (0.5 in), is typically appropriate for pediatric deltoid injections to avoid deep penetration
Correct Answer is A
Explanation
A 30-degree angle of elevation of the head of the bed is recommended for clients with spinal fusion surgery to help reduce pressure on the surgical site. It also promotes proper spinal alignment, and minimizes excessive strain on the surgical incision or spinal hardware displacement.
B. Protective isolation is not indicated for adolescents postoperative following scoliosis repair with Harrington rod instrumentation unless there are specific medical reasons, such as immunocompromised status.
C. Use of a PCA for pain management post spinal surgery is not appropriate. Other modes such oral should be explored for pain control
D. Log rolling is a technique used to safely reposition clients with spinal precautions to prevent twisting the spine.
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