Author Question: The nurse is examining a 5-year-old boy. Which of the following would the nurse interpret as a ... (Read 65 times)

waynest · **on:** Jun 27, 2018

The nurse is examining a 5-year-old boy. Which of the following would the nurse interpret as a reliable first indicator of respiratory illness in children?

A) Slow, irregular breathing
B) A bluish tinge to the lips
C) Lethargy and listlessness
D) Rapid, shallow breathing

Question 2

A breast biopsy indicates the presence of malignant cells, and the client is scheduled for a mastectomy. Which nursing diagnosis would the nurse most likely include in the client's preoperative plan of care as being the most important?

A) Risk for deficient fluid volume
B) Activity intolerance
C) Disturbed body image
D) Impaired urinary elimination

brbarasa · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

D
Response:
Tachypnea, or rapid, shallow breathing, is often the first sign of respiratory illness in infants and children. Slow, irregular breathing, lethargy, and listlessness are signs that condition of the child is deteriorating. Cyanosis (a bluish tinge to the lips) or the degree of cyanosis present is not always an accurate indication of the severity of respiratory involvement.

Answer to Question 2

C
Response:
The diagnosis of breast cancer and subsequent removal of the breast via surgery can affect all aspects of life for the woman, but most significantly her body image due to the loss of a body part. Therefore, the most important nursing diagnosis would be disturbed body image. Deficient fluid volume, activity intolerance, and impaired urinary elimination are possible due to the effects of surgery, but these are not as important as the client's body image.