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
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.
Correct Answer is B
Explanation
A. Coughing indicates a normal protective mechanism when the toddler is attempting to dislodge and cough out the food.
B. Inability to speak is a significant sign of choking and indicates that the airway is nearly completely obstructed.
C. Gagging shows that the toddler is partially obstructed and still attempting to dislodge the food
D. Pulse of 100 Beats per minute is not a direct indicator of choking.
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