A nurse is collecting data from a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status?
(Select All that Apply.)

Warm extremities

Wheezing

Nasal flaring

Retraction of sternal muscles

Oxygen saturation 95%

Answer and Explanation

Correct Answer : B,C,D

B. Wheezing is a common symptom of asthma exacerbation and can indicate airway obstruction. Wheezing may worsen during an asthma attack, suggesting deterioration in respiratory status.

C. Nasal flaring is a sign of increased respiratory effort and can occur during respiratory distress. In a child with asthma, nasal flaring may indicate worsening airway obstruction and increased work of breathing, suggesting deterioration in respiratory status.

D. Retraction of sternal muscles, also known as intercostal retractions, occurs when the muscles between the ribs are drawn inward during inspiration, indicating increased effort to breathe. Intercostal retractions are a sign of respiratory distress and can occur in children with asthma during exacerbations, particularly when airway obstruction is severe.

A. Warm extremities are not typically indicative of deterioration in respiratory status in a child with asthma. In fact, warm extremities may suggest adequate peripheral perfusion.

E. An oxygen saturation of 95% is within the normal range for most children and may not necessarily indicate deterioration in respiratory status. However, oxygen saturation should be interpreted in conjunction with other clinical signs and symptoms.

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Correct Answer is A

Explanation

A. Kawasaki disease is a systemic vasculitis that predominantly affects medium-sized arteries, including the coronary arteries of the heart. The inflammation of the blood vessels can lead to coronary artery aneurysms and other cardiovascular complications if not promptly treated.

B. The respiratory system is not primarily affected by Kawasaki disease. While Kawasaki disease is a systemic illness that can cause fever and inflammation, it primarily affects the cardiovascular system, with inflammation of blood vessels, particularly the coronary arteries.

C. The integumentary system (skin, hair, nails) is not primarily affected by Kawasaki disease. Although some children with Kawasaki disease may develop a rash, particularly in the acute phase of the illness, skin involvement is not the primary feature of the disease.

D. Gastrointestinal symptoms, such as abdominal pain, vomiting, or diarrhea, can occur in Kawasaki disease but they are not the primary focus of the disease. Kawasaki disease primarily affects the cardiovascular system, leading to inflammation of blood vessels and potential complications such as coronary artery aneurysms.

A. Periodic episodes of wheezing B. Low-grade fever in the afternoon C. Abrupt onset of D. set of sharp pleuritic pain

Correct Answer is A

Explanation

A. Wheezing, which is a high-pitched whistling sound heard during expiration, is a common symptom of asthma. It occurs due to narrowed airways and airflow obstruction, often in response to triggers such as allergens, respiratory infections, or exercise.

B. Low-grade fever in the afternoon is not typically associated with asthma. Fever is more commonly seen in response to infections, such as respiratory infections, which can exacerbate asthma symptoms but is not a direct manifestation of asthma itself.

C. Without the complete statement, it is difficult to assess its relevance to asthma symptoms. However, an abrupt onset of symptoms, such as sudden shortness of breath or chest tightness, may occur during an asthma attack or exacerbation.

D. Sharp pleuritic pain is not a typical finding in asthma. Pleuritic pain, which is sharp and worsened by breathing, is more commonly associated with conditions affecting the pleura, such as pneumonia or pleurisy.

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A nurse is collecting data from a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status? (Select All that Apply.)

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A nurse is collecting data from a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status?
(Select All that Apply.)