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 C
Explanation
A. Infants at 7 months of age begin to develop a pincer grasp, which involves using the thumb and index finger to pick up small objects. This is considered a normal developmental milestone.
B. Development of food preferences is a normal aspect of infant development as they explore different tastes and textures and, therefore, no need for further evaluation.
C. Infants at 7 months of age exhibit more advanced language development compared to earlier months. Babbling one-syllable sounds is a milestone expected by this age, and a lack of babbling may indicate a delay in language development warranting further evaluation by a healthcare provider.
D. Stranger anxiety typically emerges around 6 to 9 months of age as infants become more aware of unfamiliar people and may exhibit fear or discomfort in their presence. This is considered a normal developmental stage
Correct Answer is D
Explanation
The nurse should prepare a total of 42 units in the insulin syringe, which is the sum of 14 units of regular insulin and 28 units of NPH insulin. Combining both types of insulin in one syringe is a common practice for clients who require multiple types of insulin, allowing for a single injection.
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