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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: It is important to empty the bladder completely to prevent urine from remaining in the bladder, which can promote bacterial growth. However, this choice is not specific to teaching and is a general practice for anyone.
Choice B reason: Wearing cotton underpants is recommended because cotton is breathable and reduces moisture buildup, which can create an environment conducive to bacterial growth. The normal range for breathability in fabrics is not quantifiable but is a qualitative characteristic.
Choice C reason: Wiping from front to back helps prevent the spread of bacteria from the anal area to the urethra, which can reduce the risk of UTI. This is a key teaching point for preventing UTI recurrence.
Choice D reason: Bubble baths can irritate the urethral opening and are associated with an increased risk of UTIs, especially in children. Avoiding them is a preventive measure that should be included in the teaching.
Choice E reason: Watching for manifestations of infection, such as fever, pain, or changes in urine, is crucial for early detection and treatment of UTIs. Parents should be taught to monitor these signs closely.
Correct Answer is D
Explanation
Choice A reason: Preschool-age children are beginning to understand causality, but they do not fully grasp the cause of illnesses, which often involves complex biological processes.
Choice B reason: While preschoolers are becoming more aware of their bodies, they typically do not have a detailed understanding of body functioning.
Choice C reason: Preschoolers may describe how they feel when they are ill, but they usually cannot accurately describe the manifestations of illnesses.
Choice D reason: Preschoolers often engage in magical thinking, where they believe their thoughts can cause events. This is a normal part of their cognitive development and can include relating fears to magical thinking.
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