A parent rushes their 3-year-old child to the emergency department with an asthma exacerbation.
Which additional finding should alert the nurse that the child is in acute respiratory distress?
Diaphragmatic respirations.
Bilateral bronchial breath sounds.
Flaring of the nares.
A resting respiratory rate of 35 breaths/minute.
The Correct Answer is C
Choice A rationale
Diaphragmatic respirations are a normal breathing pattern and do not indicate respiratory distress. In fact, diaphragmatic breathing can be beneficial for patients with respiratory conditions as it helps to maximize lung expansion and improve oxygenation. Therefore, this finding is not indicative of acute respiratory distress in a child with asthma.
Choice B rationale
Bilateral bronchial breath sounds are usually heard over the large airways, such as the trachea and the main bronchi, and are not typically associated with acute respiratory distress. Wheezing or diminished breath sounds would be more indicative of airway obstruction and respiratory distress in a child with asthma.
Choice C rationale
Flaring of the nares is a sign of increased respiratory effort and is commonly seen in children with acute respiratory distress. This indicates that the child is struggling to breathe and is using additional muscles to help with respiration, which is a concerning sign that requires immediate attention.
Choice D rationale
A resting respiratory rate of 35 breaths per minute is elevated for a 3-year-old child but is not the most specific sign of acute respiratory distress. While tachypnea can indicate respiratory distress, other signs, such as nasal flaring, retractions, and cyanosis, are more specific indicators of the severity of the child's condition. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["25"]
Explanation
Step 1: Calculate the total daily dose in mg: 25 kg × 10 mg/kg/day = 250 mg/day.
Step 2: Determine how many mL are needed to administer the 250 mg dose: (250 mg ÷ 50 mg) × 5 mL = (5) × 5 mL = 25 mL. Final calculated answer: 25 mL.v
Correct Answer is A
Explanation
Choice A rationale
Collecting a urine sample to screen for protein is essential as proteinuria is a key indicator of preeclampsia, a condition characterized by high blood pressure and potential organ damage during pregnancy. Early detection is vital to manage the condition and prevent complications.
Choice B rationale
Asking about a history of delivering large babies (macrosomia) is not immediately relevant to the current symptoms of headache and elevated blood pressure, which are more indicative of hypertensive disorders rather than previous birth weights.
Choice C rationale
Examining the client for pedal edema is important but not the immediate priority. While edema can be associated with preeclampsia, the presence of proteinuria and elevated blood pressure are more critical indicators that need to be addressed first.
Choice D rationale
Establishing the frequency of headaches is useful information but not the immediate priority. The combination of an excruciating headache and elevated blood pressure necessitates a more urgent assessment for preeclampsia, starting with a urine sample for protein.
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