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 D
Explanation
A. Most schools have policies allowing children to return to school once they have been treated for head lice, even if nits are still present. Complete nit removal can be challenging, and some nits may remain after treatment.
B. Treating all family members is indeed a recommended practice to prevent the spread of head lice within the household. However, this statement alone does not encompass all aspects of managing pediculosis capitis.
C. Throwing out toys that cannot be dry cleaned or washed is unnecessary and wasteful. The focus should be on thoroughly cleaning and treating the affected person's personal items and surroundings.
D. Washing recently used clothing, bedding, and towels in hot water is an important measure to eliminate head lice and their eggs (nits) from the environment. Hot water helps kill lice and their eggs effectively. This action is a crucial part of the treatment and prevention strategy for pediculosis capitis.
Correct Answer is B
Explanation
Pyloric stenosis is characterized by the narrowing of the pylorus, the opening between the stomach and the small intestine. This narrowing obstructs the passage of food from the stomach to the small intestine, leading to symptoms such as projectile vomiting.
A. Red currant jelly stools are typically associated with intussusception - telescoping of one segment of the intestine into another.
C. Distended neck veins are not typically associated with pyloric stenosis. Distended neck veins may occur in conditions such as heart failure or superior vena cava obstruction.
D. Ridged abdomen: Pyloric stenosis may lead to a palpable olive-shaped mass in the right upper quadrant of the abdomen, but a ridged abdomen is not a typical finding.
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