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
A. Booster seats are used for older children who have outgrown their forward-facing car seats. A 24- month-old toddler is typically too young and small for a booster seat.
B. Rear-facing car seats provide the best protection for young children, including toddlers, in the event of a crash.
B. The American Academy of Pediatrics (AAP) recommends keeping children in a rear-facing car seat until they reach the maximum height or weight limit. Rear-facing seats distribute crash forces more evenly across the back of the car seat and the child's body, reducing the risk of injury to the head, neck, and spine.
C. Placing a car seat forward-facing in the front passenger side and inactivating the airbag is not recommended for any child under the age of 13 due to the risk of injury from the airbag in the event of a crash.
D. Placing a car seat rear-facing in the front passenger side is not recommended, especially for a toddler.
Correct Answer is D
Explanation
A. This question is not relevant to the assessment for acute rheumatic fever. ARF is not a congenital cardiac defect but rather an acquired condition resulting from an abnormal immune response to a streptococcal infection.
B. Injuries are not typically associated with the development of acute rheumatic fever. ARF is primarily triggered by an untreated or inadequately treated streptococcal infection, particularly streptococcal pharyngitis.
C. Aspirin use is not a specific question related to the assessment of acute rheumatic fever. Aspirin therapy may be indicated for managing symptoms of ARF, but it is not a diagnostic criterion for the condition.
D. Acute rheumatic fever (ARF) is an autoimmune condition affecting the heart, joints, skin, and central nervous system. It follows an untreated or inadequately treated group A streptococcal infection, particularly streptococcal pharyngitis (strep throat).
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