Two hours after admission for asthma exacerbation, the ...

[Metfan725]

Two hours after admission for asthma exacerbation, the 10-year-old boy is lethargic with mottled skin color. He has increased the use of accessory muscles and demonstrates nasal flaring.
 
  He is unable to speak and his respiratory rate has increased. The nurse would suspect: 1. Improvement in his condition is imminent.
  2. Respiratory failure is imminent.
  3. The medical diagnosis is incorrect and the child should be diagnosed with pneumonia.
  4. The child may be receiving too much oxygen, which is a respiratory depressant.

Question 2

A group of children on one hospital unit are all suffering separation anxiety. When determining the stages of separation anxiety, the nurse recognizes that the child in the despair phase is the child who:
 
  1. Lies quietly in bed.
  2. Does not cry if his parents return and leave again.
  3. Appears to be happy and content with staff.
  4. Screams and cries when his parents leave.

[mariahkathleeen]

Answer to Question 1

2
Rationale 1: His condition has worsened.
Rationale 2: These are symptoms of impending failure. Intervention is necessary.
Rationale 3: Pneumonia is a complication of asthma exacerbation but that doesn't indicate the medical diagnosis is incorrect.
Rationale 4: There is no indication the child is receiving too much oxygen.
Global

Answer to Question 2

1
Rationale 1: Children in the despair stage appear sad, depressed, or withdrawn. A child who is lying in bed might be exhibiting any of these.
Rationale 2: The young child who appears to be happy and content with everyone is in the denial stage, as is the child who does not cry if his parents return and leave again.
Rationale 3: The young child who appears to be happy and content with everyone is in the denial stage, as is the child who does not cry if his parents return and leave again.
Rationale 4: Screaming and crying are components of the protest stage.
Global Rationale: