A nurse is caring for a child who is having difficulty breathing due to an asthma exacerbation. Which of the following areas should the nurse determine if the child is experiencing subcostal retractions? (You will find hot spots to select in the artwork below. Select only the hot corresponds to your answer.)
The Correct Answer is "{\"xRanges\":[232.4270782470703,272.4270782470703],\"yRanges\":[382.1666450500488,422.1666450500488]}"
To determine if the child is experiencing subcostal retractions, check the area beneath the ribcage.
D - Subcostal Area:
Subcostal retractions occur below the ribs and are a sign of respiratory distress, indicating increased effort to breathe.
Observing this area can reveal inward movement during inspiration, suggesting difficulty in breathing, often seen in asthma exacerbations.
Rationale
A - Incorrect:
This area is near the clavicle and not related to subcostal retractions.
B - Incorrect:
This is the intercostal area, which can also show retractions but is not subcostal.
C - Incorrect:
This area is too central and does not correspond with subcostal retractions.
Focusing on D allows the nurse to assess the presence of subcostal retractions effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Talking with the client's family to determine how the condition affects the client role:
Understanding the client's role within the family is important for comprehensive care, but it is not the most immediate priority in discharge planning. This information can be gathered once the client has the tools to manage their condition effectively.
B) Assessing the impact of the client's body image changes:
While body image is a significant concern for many clients with chronic conditions, it does not directly affect the immediate physical ability to manage daily activities and pain, which is crucial for someone with osteoarthritis.
C) Giving the client printed information about when to use hot and cold therapy:
Providing education on managing symptoms is essential, but simply giving printed information might not address the client's immediate need for practical assistance and adaptations necessary for self-care at home.
D) Consulting occupational therapy to provide assistive devices for self-care:
Ensuring the client has access to assistive devices through occupational therapy is the priority because it directly addresses their ability to perform activities of daily living independently and safely. This intervention can significantly improve the client’s quality of life and reduce the risk of complications.
Correct Answer is D
Explanation
A) Discontinue the overhead trapeze:
The overhead trapeze can be beneficial for the client to assist with repositioning and mobility, especially postoperatively. Removing it would hinder the client's ability to move independently and could increase the risk of complications from immobility.
B) Turn the client every 6 hr while in bed:
Turning the client every 6 hours is insufficient for preventing complications such as pressure ulcers. Standard care involves repositioning the client at least every 2 hours to maintain skin integrity and promote circulation.
C) Remind the client that phantom limb pain does not need treatment:
Phantom limb pain is a real and often distressing condition for many amputees. It requires appropriate treatment and management strategies to ensure the client's comfort and psychological well-being. Dismissing the pain can lead to increased distress and hinder recovery.
D) Assist the client to a prone position every 3 hr:
Positioning the client in a prone position regularly helps prevent contractures, particularly hip flexion contractures, which are common after lower limb amputations. This position can stretch the hip muscles and aid in maintaining proper alignment and mobility, making it a beneficial intervention in postoperative care.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.