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 B

Explanation

A. Maintenance of good posture. While good posture can promote better bowel motility, it is not a primary intervention for constipation.

B. Increased fiber and fluid in the diet. Increasing dietary fiber (whole grains, fruits, vegetables) and fluid intake softens stool and promotes regular bowel movements, making this the best recommendation.

C. Regular use of a laxative. Frequent use of stimulant laxatives can lead to dependence, making it an inappropriate first-line intervention.

D. Regular use of glycerin suppositories. Glycerin suppositories are used for occasional relief of constipation but are not recommended for routine use as they do not address the underlying cause.

A. Itching and scratching of the head B. Patchy areas of hair loss C. Firmly attached white particles on the hair D. Thick, yellow-crusted lesions on a red base

Correct Answer is C

Explanation

A. Itching and scratching of the head. While itching is a common symptom, it is not a definitive sign of head lice. Other conditions (e.g., dandruff, seborrheic dermatitis, or dry scalp) can also cause itching.

B. Patchy areas of hair loss. Hair loss is not a characteristic sign of head lice. It may indicate alopecia areata or tinea capitis (scalp ringworm) instead.

C. Firmly attached white particles on the hair. The presence of nits (lice eggs) that are firmly attached to the hair shaft near the scalp is a definitive sign of pediculosis capitis. Nits do not flake off like dandruff and are difficult to remove.

D. Thick, yellow-crusted lesions on a red base. This describes impetigo, a bacterial skin infection, not head lice.

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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 is pregnant and reports constipation. Which of the following recommendations should the nurse make?

Correct Answer is B

Explanation

A nurse is checking a school-age child for pediculosis capitis (head lice). Which of the following findings is a definitive indication of this condition?

Correct Answer is C

Explanation

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