A parent rushes their 3-year-old child to the emergency department with an asthma exacerbation.
Which additional finding should alert the nurse that the child is in acute respiratory distress?
Diaphragmatic respirations.
Bilateral bronchial breath sounds.
Flaring of the nares.
A resting respiratory rate of 35 breaths/minute.
The Correct Answer is C
Choice A rationale
Diaphragmatic respirations are a normal breathing pattern and do not indicate respiratory distress. In fact, diaphragmatic breathing can be beneficial for patients with respiratory conditions as it helps to maximize lung expansion and improve oxygenation. Therefore, this finding is not indicative of acute respiratory distress in a child with asthma.
Choice B rationale
Bilateral bronchial breath sounds are usually heard over the large airways, such as the trachea and the main bronchi, and are not typically associated with acute respiratory distress. Wheezing or diminished breath sounds would be more indicative of airway obstruction and respiratory distress in a child with asthma.
Choice C rationale
Flaring of the nares is a sign of increased respiratory effort and is commonly seen in children with acute respiratory distress. This indicates that the child is struggling to breathe and is using additional muscles to help with respiration, which is a concerning sign that requires immediate attention.
Choice D rationale
A resting respiratory rate of 35 breaths per minute is elevated for a 3-year-old child but is not the most specific sign of acute respiratory distress. While tachypnea can indicate respiratory distress, other signs, such as nasal flaring, retractions, and cyanosis, are more specific indicators of the severity of the child's condition. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1500"]
Explanation
Step 1 is. (500 mL ÷ 20 min) × 60 min/hr = 1500 mL/hr. Answer: 1500 mL/hr.
Correct Answer is A
Explanation
Choice A rationale
Projectile vomiting in an infant with an olive-like mass in the abdomen suggests pyloric stenosis. This condition causes severe vomiting due to gastric obstruction. It's a hallmark symptom and requires monitoring and surgical intervention.
Choice B rationale
While arching the back can occur in various conditions, it is not specifically indicative of pyloric stenosis. It could be a sign of discomfort or other neurological issues but not directly related to the gastrointestinal obstruction seen in pyloric stenosis.
Choice C rationale
Frequent pauses during feeding are common in many infant conditions and are not specific to pyloric stenosis. They indicate general feeding difficulties but are not diagnostic of this particular condition.
Choice D rationale
Coffee-ground emesis indicates bleeding in the gastrointestinal tract but is not typical of pyloric stenosis. The hallmark sign is non-bloody, forceful vomiting due to gastric outlet obstruction.
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