A nurse is caring for a 5-year-old child in the acute care setting.
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Child remains in bed. Child uncooperative and agitated, Refusing PO fluids. Child reports chest pain and joint pain as a 4 on the Faces Scale. Nasal flaring and moderate subcostal and substernal retractions are noted. Bilateral, moderate inspiratory and expiratory wheezes noted upon auscultation. Voided 200 mL of clear yellow urine
Child reports chest pain and joint pain as a 4 on the Faces Scale.
Nasal flaring and moderate subcostal and substernal retractions are noted.
Bilateral
moderate inspiratory and expiratory wheezes noted upon auscultation.
The Correct Answer is ["A","B","C","D"]
These findings indicate that the child is experiencing significant pain, which is concerning, especially considering the history of sickle cell anemia and the recent increase in pain despite previous management with acetaminophen. Chest pain could also be indicative of a vaso-occlusive crisis or a respiratory complication.
Nasal flaring and moderate subcostal and substernal retractions are noted:
Nasal flaring and retractions suggest increased work of breathing, which could indicate respiratory distress. In a child with sickle cell anemia, respiratory complications like acute chest syndrome are a significant concern during a vaso-occlusive crisis.
Bilateral, moderate inspiratory and expiratory wheezes noted upon auscultation:
Wheezing indicates airway obstruction or inflammation, which could be due to asthma exacerbation, infection, or acute chest syndrome, all of which are common complications in children with sickle cell disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Nephrotic syndrome is a renal condition characterized by increased permeability of the glomerular filtration barrier, leading to excessive protein loss in the urine. Cardinal features include : (proteinuria), hypoalbuminemia, edema, and hyperlipidemia.
B. Hypertension: While hypertension can occur in some cases of nephrotic syndrome, it is not a consistent finding.
C. Smokey brown urine: Smokey brown urine can be a sign of rhabdomyolysis or hemolysis, not nephrotic syndrome. In nephrotic syndrome, urine may appear foamy due to proteinuria
D. Polyuria: Polyuria is not a typical finding in nephrotic syndrome. Nephrotic syndrome is more commonly associated with oliguria (decreased urine output) due to decreased blood volume and activation of the renin-angiotensin-aldosterone system.
Correct Answer is A
Explanation
When assesssing the child with suspected or confirmed Wilm's tumor, it is important to avoid palpation of the abdomem. This is because it can lead to dislodging of the tumor cells
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