The nurse caring for a male child with respiratory problems is concerned he may be developing respiratory failure
Upon assessment, the nurse knows that which of the following are clinical manifestations of respiratory failure? Select all that apply.
A)
Severe accessory muscle retractions
B)
Nasal flaring
C)
Grunting on expiration
D)
Inspiratory wheezes heard
E)
Swollen glottis
Ans:
A, B, C
Feedback:
Children with impending respiratory failure due to airway or lung disease have rapid breathing; exaggerated use of the accessory muscles; retractions, which are more pronounced in the child than in an adult because of more compliant chest; nasal flaring; and grunting during expiration. Inspiratory wheezes are usually associated with asthma. Swollen glottis can occur with strep throat.
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