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%
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Warm compresses or heat therapy are not recommended for the initial management of a sprained ankle, especially within the first 24 hours. Heat can increase blood flow and exacerbate swelling and inflammation, which may worsen pain and delay healing.
A. Applying ice packs in this manner helps reduce inflammation and swelling, which are common after a sprain. Alternating ice application with periods of rest allows for effective cooling without causing tissue damage.
B. Wrapping the ankle in an Ace bandage can provide compression and support, which may help reduce swelling and stabilize the joint during the healing process. However, it's important not to wrap the bandage too tightly, as this can impair circulation.
C. Elevating the leg when sitting helps reduce swelling by promoting venous return and preventing fluid accumulation in the injured area. Keeping the ankle elevated above the level of the heart whenever possible is recommended for optimal swelling reduction.
Correct Answer is C
Explanation
C. This is characteristic of Kernig's sign. Kernig's sign is elicited when the thigh is flexed at the hip and then attempts to extend the leg at the knee are met with resistance or pain due to inflammation of the meninges.
A. Petechial and purpuric rashes are associated with meningococcal meningitis, not specifically with Kernig's sign. These rashes result from bleeding into the skin and are a characteristic feature of meningococcal sepsis. However, they are not directly related to Kernig's sign.
B. This observation describes Brudzinski's sign, not Kernig's sign. Brudzinski's sign occurs when passive flexion of the neck causes involuntary flexion of the hips and knees due to meningeal irritation.
D. Muscle and joint pain can be symptoms of meningitis, but they are not specific to Kernig's sign. Kernig's sign specifically refers to resistance or pain experienced when attempting to extend the leg at the knee.
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