A child is being evaluated for increased work of breathing. While inspecting the child's chest, the nurse notes pulling in or sucking in of the skin between the child's ribs. How might the nurse accurately document this finding?

Nasal flaring present.

Suprasternal retractions present.

Intercostal retractions present.

Subcostal retractions present.

Answer and Explanation

The Correct Answer is C

A. Nasal flaring present. Nasal flaring is a separate sign of respiratory distress, but it does not describe retractions.

B. Suprasternal retractions present. Suprasternal retractions occur above the sternum, not between the ribs.

C. Intercostal retractions present. Intercostal retractions occur between the ribs and indicate difficulty breathing due to increased respiratory effort.

D. Subcostal retractions present. Subcostal retractions occur below the ribcage, not between the ribs.

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Correct Answer is A

Explanation

A. Stress incontinence. Stress incontinence occurs when intra-abdominal pressure (e.g., sneezing, coughing, laughing) causes urine leakage due to weak pelvic floor muscles or urethral sphincter dysfunction.

B. Reflex incontinence. Reflex incontinence is involuntary urination without warning due to neurological dysfunction (e.g., spinal cord injury, multiple sclerosis), which is not the case here.

C. Urge incontinence. Urge incontinence is a sudden, intense need to urinate, often caused by overactive bladder syndrome or neurological disorders. It is not associated with sneezing.

D. Overflow incontinence. Overflow incontinence occurs when the bladder fails to empty completely, leading to dribbling of urine due to urinary retention (e.g., BPH, diabetic neuropathy).

A. Denial of pruritus B. Reports of joint discomfort C. Reports of exposure to a skin irritant D. Elevated temperature

Correct Answer is C

Explanation

A. Denial of pruritus. Pruritus (itching) is a hallmark symptom of contact dermatitis, so its denial would be unusual.

B. Reports of joint discomfort. Joint pain is not a characteristic feature of contact dermatitis; it is more common in systemic inflammatory conditions such as arthritis.

C. Reports of exposure to a skin irritant. Contact dermatitis is caused by direct contact with an irritant or allergen, so a history of exposure is a key finding.

D. Elevated temperature. Fever is not typical of contact dermatitis unless an infection is present.

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A child is being evaluated for increased work of breathing. While inspecting the child's chest, the nurse notes pulling in or sucking in of the skin between the child's ribs. How might the nurse accurately document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who tells the nurse she experiences urinary incontinence when she sneezes. The nurse recognizes this is an expected finding for which of the following types of incontinence?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has contact dermatitis of the neck and upper chest. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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