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 D

Explanation

A. "Right now, I can't bathe or dress myself, but my family will help me." Dependence on family for basic self-care suggests the client is not yet independent enough for discharge.

B. "I can always come stay in the hospital again if I don't want to take care of my own needs." This statement shows a lack of commitment to self-care and reliance on hospitalization as a coping mechanism.

C. "Taking care of myself is important, but it's okay if I don't want to do anything." Readiness for discharge includes a commitment to self-care, and this statement suggests a lack of motivation.

D. "I will take my medicines as I should and know who to call if I have bad thoughts." This statement shows insight into the importance of medication adherence and knowledge of available support resources, indicating readiness for discharge.

A. Urinary frequency B. Urinary tract infection C. Urinary retention D. Urinary incontinence

Correct Answer is B

Explanation

A. Urinary frequency. Urinary frequency is an increased urge to void, which can be caused by a UTI but does not explain cloudy, foul-smelling urine on its own.

B. Urinary tract infection (UTI). Cloudy, dark amber urine with a foul odor is indicative of a UTI due to bacterial presence, pus (pyuria), and possibly hematuria.

C. Urinary retention. Urinary retention leads to distended bladder, incomplete emptying, and overflow incontinence, but it does not cause foul-smelling, cloudy urine unless it leads to secondary infection.

D. Urinary incontinence. Incontinence is the involuntary loss of urine, but it does not cause cloudy or foul-smelling urine unless there is an underlying infection.

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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 assisting in the care of a client who has a mood disorder. Which of the following client statements by the client indicates readiness for discharge?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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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?

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