The emergency room triage nurse is assessing a child who has a history of a cough and nasal congestion for the last three days. When assessing patency of the nares, the nurse notes that the child is unable to breathe through the right nostril
The nurse would interpret these assessment findings as which of the following? 1. Produced by severe nasal inflammation or obstruction
2. Normal for a child
3. A result of chronic allergies
4. A result of sinusitis
1
Rationale 1: If the client cannot breathe through each naris, severe inflammation or an obstruction may be present.
Rationale 2: This is not a normal finding in an adult or a child.
Rationale 3: If nasal mucosa is pale and boggy or swollen, the client may have chronic allergies. Due to the client's history, this is an acute problem and not associated with chronic allergies.
Rationale 4: The client with sinusitis will have tenderness over sinus cavities.
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