A nurse is caring for a 5-year-old child in the acute care setting.

exhibits

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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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Neuroblastoma is a type of cancer that arises from immature nerve cells and commonly affects infants and young children. While it can occur in the abdomen, it is not primarily a renal tumor.
B. Ewing sarcoma is a type of bone cancer that primarily affects children and adolescents. It typically arises in the bones of the pelvis, legs, arms, ribs, or spine. While it can involve the abdominal area if it metastasizes (spreads), it is not primarily an intra-abdominal tumor.
C. Osteosarcoma commonly arises in the long bones of the arms and legs. While it can spread to other parts of the body, including the abdomen, it is primarily a bone tumor.
D. Wilms' tumor, also known as nephroblastoma, is the most common malignant renal (kidney) tumor of childhood. It typically occurs in children around 2 to 5 years old and is often detected as a firm, non- tender abdominal mass.

A. Keep the head of the bed at a 30" angle. B. Place the client in protective isolation. C. Initiate the use of a PCA pump for pain control. D. Reposition the client by log rolling every 4 hr.

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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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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