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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Clubbing, characterized by bulbous enlargement of the fingertips and nail bed, is a result of chronic hypoxia in tetralogy of Fallot. In tetralogy of Fallot, there is a right-to-left shunting of blood due to the presence of a ventricular septal defect, overriding aorta, pulmonary stenosis, and right ventricular hypertrophy. This leads to reduced oxygenation of blood and chronic hypoxia, which can result in clubbing of the fingertips over time.
A This option is not the primary explanation for clubbing in tetralogy of Fallot. While decreased cardiac output may contribute to some manifestations of the condition, clubbing specifically results from chronic hypoxia rather than decreased cardiac output alone.
B Clubbing is not directly caused by a left-to-right shunting of blood. Instead, it is associated with chronic hypoxia, which can occur due to right-to-left shunting of blood in tetralogy of Fallot.
D Congestive heart failure may occur in individuals with tetralogy of Fallot but it is not the primary cause of clubbing. Clubbing in tetralogy of Fallot is primarily attributed to chronic hypoxia rather than heart failure alone.
Correct Answer is D
Explanation
D. The aim is to focus on the child's strengths and abilities while addressing limitations and challenges associated with the condition. This approach emphasizes maximizing the child's potential for development, independence, and participation in daily activities, education, and social interactions, while also providing support and resources to address any limitations or barriers they may encounter.
A. Another goal of treatment and care is to maximize the child's functional abilities by improving muscle control, coordination, and mobility through various therapies, such as physical therapy, occupational therapy, and speech therapy. However, this is not the primary goal.
B. Cerebral palsy is a neurological condition caused by damage to the developing brain, often occurring before birth. While efforts to prevent cerebral palsy are important, once the condition has developed, the focus shifts to managing symptoms and optimizing the child's functioning rather than eliminating the cause.
C. Emotional well-being is an important aspect of overall health for children with cerebral palsy but it is not typically the primary goal of care. Emotional disturbances may occur in some children with cerebral palsy due to various factors such as coping with the challenges of the condition, social interactions, or other comorbidities, but the primary focus of the care plan is usually on addressing physical and functional impairments.
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