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 B
Explanation
Turning and repositioning the client at regular intervals is essential for preventing pressure ulcers in pediatric clients, especially those in the PICU who may be immobilized or have limited mobility due to their condition or treatment. Repositioning helps relieve pressure on bony prominences and redistributes pressure on the skin, reducing the risk of pressure ulcers. Turning schedules should be individualized based on the child's condition, mobility, and risk factors for pressure ulcers.
A. Avoid the use of a draw sheet when turning: Using a draw sheet can facilitate safe and smooth turning of the client without causing shear or friction forces. It helps distribute the weight evenly and reduces the risk of injury to the client or caregiver during the turning process. Therefore, avoiding the use of a draw sheet may increase the risk of pressure ulcers rather than prevent them.
B. Post a turning schedule at the client's bedside: While posting a turning schedule may serve as a reminder for staff, it alone does not provide direct intervention to prevent pressure ulcers. The crucial aspect is implementing the turning schedule consistently and ensuring that the client is repositioned at appropriate intervals.
C. Vigorously massage lotion into bony prominences: Massaging lotion into bony prominences can increase friction and shear forces on the skin, potentially causing tissue damage rather than preventing pressure ulcers. Additionally, vigorous massage may be uncomfortable or painful for the client, especially if they have fragile skin or existing pressure ulcers.
Correct Answer is A
Explanation
Wilms' tumor, also known as nephroblastoma, is a type of kidney cancer that primarily affects children, typically between the ages of 3 and 4 years old, but it can also occur in younger children. One of the common manifestations of Wilms' tumor is the presence of a palpable abdominal mass, which may be noticed by a caregiver or healthcare provider during a physical examination. Additionally, hematuria (blood in the urine) is another common symptom associated with Wilms' tumor, leading to the observation of pink-tinged urine on the diaper.
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