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%
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Amblyopia occurs when one eye has weaker vision than the other due to abnormal visual development early in life. Patching the good eye helps to encourage the brain to rely more on the weaker eye, stimulating its visual development. This treatment aims to improve vision in the affected eye and restore visual acuity.
B. Patching the affected eye is not a common treatment for amblyopia. In fact, patching the affected eye would further decrease visual input to that eye and could potentially exacerbate the condition. The goal of treatment for amblyopia is to strengthen the weaker eye by encouraging its use, rather than resting it.
C. Corticosteroids are not typically used to treat amblyopia unless there is a specific underlying condition causing inflammation of the optic nerve. Amblyopia is primarily a developmental issue rather than an inflammatory condition, so corticosteroids would not be the first-line treatment for this condition.
D. This is not a common treatment for amblyopia. In fact, the goal of treatment for amblyopia is to improve vision in the affected eye, not to intentionally blur the vision in the good eye. Glasses prescribed for amblyopia typically aim to correct refractive errors (such as nearsightedness, farsightedness, or astigmatism) and provide clear vision to both eyes, which can help support visual development in the weaker eye.
Correct Answer is A
Explanation
A. Exposure to environmental tobacco smoke (passive smoking) is a known risk factor for otitis media, as it can irritate the upper respiratory tract and increase susceptibility to respiratory infections, including those affecting the ears.
B. Excessive earwax buildup can sometimes contribute to ear discomfort or hearing problems but it is not a common cause of persistent otitis media. However, it's still important for the nurse to assess for any earwax issues as part of the overall assessment of the child's ear health.
C. Drinking water is generally beneficial for overall health but is not directly linked to otitis media unless there are specific concerns about hydration status or exposure to contaminated water sources.
D. Water entering the ears during bathing is not generally considered a significant risk factor for otitis media, but it can be associated with otitis externa, which is an infection of the outer ear canal.
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