A nurse is assessing a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status? (Select all that apply.)

Oxygen saturation 95%

Warm extremities

Wheezing

Nasal flaring

Retraction of sternal muscles

Answer and Explanation

Correct Answer : C,D,E

Choice A reason: An oxygen saturation of 95% is within the normal range and does not indicate respiratory deterioration.

Choice B reason: Warm extremities are not an indication of respiratory status deterioration; they are generally a sign of good circulation.

Choice C reason: Wheezing is a common sign of airway obstruction in asthma and can indicate a deterioration in respiratory status.

Choice D reason: Nasal flaring is a sign of increased work of breathing and can indicate respiratory distress in a child with asthma.

Choice E reason: Retraction of sternal muscles is a sign of respiratory distress and can indicate a worsening condition in a child with asthma.

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Correct Answer is ["C","D"]

Explanation

Choice A reason: Rapid growth spurts are not associated with cystic fibrosis. Instead, patients often experience poor growth due to malabsorption.

Choice B reason: Thin, watery mucus is not typical in cystic fibrosis. The mucus is usually thick and sticky, leading to blockages in the lungs and pancreas.

Choice C reason: Wheezing is a common symptom in cystic fibrosis due to the obstruction of the airways by thick mucus.

Choice D reason: A barrel-shaped chest can develop in cystic fibrosis due to chronic lung infections and air trapping.

Choice E reason: Clubbing of fingers and toes is a sign of chronic hypoxia, which can occur in cystic fibrosis due to long-standing lung disease.

A. It is often observed in the school-age child. B. Detachment is the stage exhibited in the hospital. C. Kicking a stranger is an example. D. It results in prolonged issues of adaptability.

Correct Answer is A

Explanation

Choice A reason: Separation anxiety is common in early childhood and typically resolves as the child develops, usually by around age 2 or 3.However, it can also be present in school-age children, especially if it develops into separation anxiety disorder.

Choice B reason: This is not typically included in teaching about separation anxiety. Detachment might be a response to prolonged separation or hospitalization, but it is not a stage of separation anxiety.

Choice C reason:

While kicking a stranger can be a manifestation of separation anxiety, it’s more constructive to focus on common symptoms such as excessive worry when apart from home or family, or panic and fear at the time of separation

Choice D reason: Separation anxiety that is severe and persistent can lead to challenges in adaptability and functioning. It’s important for caregivers to recognize symptoms and seek help if the anxiety interferes with daily life.

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A nurse is assessing a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing an admission assessment for a child who has cystic fibrosis. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["C","D"]

Explanation

A nurse is teaching a group of caregivers about separation anxiety. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

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