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. This is the correct characteristic of decerebrate posturing. Decerebrate posturing is characterized by rigid extension and pronation (turning inward) of the arms and legs. It indicates severe neurological dysfunction and increased intracranial pressure, often involving damage to the brainstem.

A. This characteristic is not associated with decerebrate posturing. Adduction refers to movement toward the midline of the body, which is not typically observed in decerebrate posturing.

B. This description is not characteristic of decerebrate posturing. Decerebrate posturing involves extension, not flexion, of the upper extremities, along with extension and pronation (not adduction) of the lower extremities.

C. Flaccid paralysis refers to the absence of muscle tone and movement, which is not characteristic of decerebrate posturing. Decerebrate posturing involves increased muscle tone and abnormal, rigid extension of the arms and legs.

A. Clubbing occurs as a result of decreased cardiac output. B. Clubbing occurs as a result of a left-to-right shunting of blood. C. Clubbing occurs as a result of chronic hypoxia D. Clubbing occurs as a result of untreated congestive heart failure.

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.

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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

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing?

Correct Answer is D

Explanation

The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, "Why do my child's fingertips look like that?" On what understanding does the nurse base a response?

Correct Answer is C

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.)