A nurse collecting data from a child who has cystic fibrosis. Which of the following findings should the nurse expect? (select all that apply)
Wheezing
Barrel-shaped chest
Thin, watery mucous
Clubbing of fingers and toes
Rapid growth spurts
Correct Answer : A,B,D
A. Wheezing. Cystic fibrosis can cause airway obstruction due to thickened mucus, leading to wheezing and difficulty breathing, especially during respiratory infections or exacerbations.
B. A barrel-shaped chest is often seen in advanced stages of cystic fibrosis. It results from hyperinflation of the lungs due to air trapping, chronic lung disease, and repeated respiratory infections. The chest appears rounded and enlarged, similar to the shape of a barrel.
D. Clubbing of fingers and toes is a common finding in cystic fibrosis. It is caused by chronic hypoxia and inadequate oxygenation of tissues, leading to changes in the nail beds and fingertips. Clubbing typically develops over time in individuals with chronic respiratory conditions, including cystic fibrosis.
C. Thin, watery mucous is not expected in cystic fibrosis. Instead, cystic fibrosis is characterized by thick, sticky mucus due to dysfunction of the exocrine glands, leading to blockages in the airways, pancreas, and other organs.
E. Rapid growth spurts are not typically associated with cystic fibrosis. In fact, children with cystic fibrosis may experience growth failure or delayed growth due to malabsorption of nutrients, chronic illness, and increased energy expenditure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Place resuscitation equipment at the child's bedside. This is because epiglottitis can lead to a life- threatening emergency requiring immediate intervention, and having resuscitation equipment readily available is essential for rapid response.
A. Establishing intravenous access may be necessary for administering fluids and medications but it is not the nurse's priority action when caring for a child with suspected epiglottitis.
B. Droplet precautions help reduce the risk of transmission of respiratory pathogens to others. However, the priority is to address the child's respiratory distress and potential airway compromise.
C. Providing blow-by humidified oxygen can be beneficial in managing the child's respiratory status. However, securing the airway takes precedence over other interventions, as indicated by the guidelines for managing epiglottitis.
Correct Answer is C
Explanation
C. This is characteristic of Kernig's sign. Kernig's sign is elicited when the thigh is flexed at the hip and then attempts to extend the leg at the knee are met with resistance or pain due to inflammation of the meninges.
A. Petechial and purpuric rashes are associated with meningococcal meningitis, not specifically with Kernig's sign. These rashes result from bleeding into the skin and are a characteristic feature of meningococcal sepsis. However, they are not directly related to Kernig's sign.
B. This observation describes Brudzinski's sign, not Kernig's sign. Brudzinski's sign occurs when passive flexion of the neck causes involuntary flexion of the hips and knees due to meningeal irritation.
D. Muscle and joint pain can be symptoms of meningitis, but they are not specific to Kernig's sign. Kernig's sign specifically refers to resistance or pain experienced when attempting to extend the leg at the knee.
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