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.
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.
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