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 D
Explanation
This position, often referred to as the "knee-to-chest" position, is recommended during a cyanotic spell in infants with tetralogy of Fallot because it can help increase venous return to the heart and improve oxygenation. It's important for caregivers to understand this positioning as part of the management for hypercyanotic spells in children with this condition.
A. Placing the baby upright in an infant seat may help improve blood flow and oxygenation, but it's not the recommended position for managing cyanosis in a baby with tetralogy of Fallot.
B. Placing the baby with the head lower than the rest of the body could potentially worsen cyanosis by increasing right-to-left shunting of blood and decreasing pulmonary blood flow.
C. Placing the baby in a supine position with the head elevated worsens pulmonary blood flow by increasing systemic vascular resistance. This position can help worsen cyanosis by promoting better oxygenation.
Correct Answer is ["A","B","D"]
Explanation
A. Wheezing. Cystic fibrosis can cause airway obstruction due to thickened mucus, leading to wheezing and difficulty breathing, especially during respiratory infections or exacerbations.
B. A barrel-shaped chest is often seen in advanced stages of cystic fibrosis. It results from hyperinflation of the lungs due to air trapping, chronic lung disease, and repeated respiratory infections. The chest appears rounded and enlarged, similar to the shape of a barrel.
D. Clubbing of fingers and toes is a common finding in cystic fibrosis. It is caused by chronic hypoxia and inadequate oxygenation of tissues, leading to changes in the nail beds and fingertips. Clubbing typically develops over time in individuals with chronic respiratory conditions, including cystic fibrosis.
C. Thin, watery mucous is not expected in cystic fibrosis. Instead, cystic fibrosis is characterized by thick, sticky mucus due to dysfunction of the exocrine glands, leading to blockages in the airways, pancreas, and other organs.
E. Rapid growth spurts are not typically associated with cystic fibrosis. In fact, children with cystic fibrosis may experience growth failure or delayed growth due to malabsorption of nutrients, chronic illness, and increased energy expenditure.
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