A nurse is collecting data from a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status?
(Select All that Apply.)

Warm extremities

Wheezing

Nasal flaring

Retraction of sternal muscles

Oxygen saturation 95%

Answer and Explanation

Correct Answer : B,C,D

B. Wheezing is a common symptom of asthma exacerbation and can indicate airway obstruction. Wheezing may worsen during an asthma attack, suggesting deterioration in respiratory status.

C. Nasal flaring is a sign of increased respiratory effort and can occur during respiratory distress. In a child with asthma, nasal flaring may indicate worsening airway obstruction and increased work of breathing, suggesting deterioration in respiratory status.

D. Retraction of sternal muscles, also known as intercostal retractions, occurs when the muscles between the ribs are drawn inward during inspiration, indicating increased effort to breathe. Intercostal retractions are a sign of respiratory distress and can occur in children with asthma during exacerbations, particularly when airway obstruction is severe.

A. Warm extremities are not typically indicative of deterioration in respiratory status in a child with asthma. In fact, warm extremities may suggest adequate peripheral perfusion.

E. An oxygen saturation of 95% is within the normal range for most children and may not necessarily indicate deterioration in respiratory status. However, oxygen saturation should be interpreted in conjunction with other clinical signs and symptoms.

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Correct Answer is D

Explanation

D. The correct action would be to place the client on NPO (Nothing by Mouth) status, option D. This is because a decreased level of consciousness can increase the risk of aspiration.

A. Liver biopsy is not indicated for suspected meningitis with a decreased level of consciousness. Liver biopsy is a procedure used to obtain a sample of liver tissue for diagnostic purposes, typically to evaluate liver function or diagnose liver diseases.

B. A protective environment (option B) is more related to immunocompromised patients. In the case of decreased level of consciousness, preventing aspiration is key.

C. Dorsal recumbent position refers to lying on the back with the knees flexed. While this position may be suitable for certain medical procedures or examinations, it is not specifically indicated for a client with suspected meningitis and a decreased level of consciousness.

A. Observation for increasing intracranial pressure B. Isolation precautions C. Turn lights on to brighten the room D. Preparation for lumbar puncture E. Apply seizure precautions

Correct Answer is ["A","B","D","E"]

Explanation

A. Observation for increasing intracranial pressure is a critical intervention in the care of a child with infectious meningitis. Meningitis can lead to inflammation of the meninges, which may result in increased pressure within the skull.

B. Isolation precautions may be necessary depending on the causative organism and mode of transmission of the infectious meningitis. Bacterial meningitis, for example, may require droplet precautions to prevent the spread of infection to others.

D. Lumbar puncture (also known as a spinal tap) is a diagnostic procedure often performed to collect cerebrospinal fluid (CSF) for analysis in cases of suspected meningitis. It is an essential intervention in the diagnostic workup of infectious meningitis as it helps identify the causative organism and guide appropriate treatment.

C. Seizure precautions are important for children with infectious meningitis, as meningitis can increase the risk of seizures due to inflammation and irritation of the brain.

C. Bright lights can exacerbate symptoms such as headache and photophobia (sensitivity to light) in patients with meningitis, especially during the acute phase of illness. Therefore, it is not advisable to turn lights on to brighten the room for a child with infectious meningitis.

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A nurse is collecting data from a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status? (Select All that Apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has suspected meningitis and a decrease level of consciousness. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

What intervention(s) would the nurse caring for a child with infectious meningitis include? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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A nurse is collecting data from a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status?
(Select All that Apply.)