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 A
Explanation
The practice as it helps prevent the backflow of stomach contents into the esophagus, which is beneficial for infants with gastroesophageal reflux.
B. This statement does not necessarily indicate an understanding of the teaching. Breast milk or formula can be used for infants with reflux; however, some formulas are designed to be easier to digest or less likely to cause reflux.
C. This is not generally recommended for infants with reflux. The safest position for all infants, including those with reflux, is on their back to reduce the risk of sudden infant death syndrome (SIDS).
D. This may be recommended in some cases to help reduce the symptoms of reflux. However, it's important to do this under the guidance of a healthcare provider to ensure it's done safely and appropriately. Thickening formula should be done with caution as it can increase the risk of choking.
Correct Answer is B
Explanation
A. Gastritis is inflammation of the stomach lining and is typically not caused by streptococcal infections. There is no direct link between gastritis and rheumatic fever.
B. Rheumatic fever is an inflammatory condition that develops as a complication of inadequately treated Group A Streptococcus (GAS) infections such as strep throat.
Therefore, a history of a sibling having a sore throat 3 weeks ago is significant because it suggests a possible streptococcal infection.
C. Fifth disease, caused by parvovirus B19, is a viral infection that primarily affects children. It is not caused by streptococcal bacteria and is not associated with the development of rheumatic fever.
D. Chickenpox, caused by the varicella-zoster virus, is a viral infection and does not predispose a child to rheumatic fever.
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