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HISTORY AND PHYSICAL A 4-year-old female client presents to the clinic with a dry cough that has persisted over the past week. The client has a history of asthma controlled with beclomethasone one to two puffs daily. No known allergies. Ht. 40 inches 38 pounds (17.2 kg) (72nd percentile) BMI 16.7 Vaccinations up to date. NURSE’S NOTES 0900: Client alert and oriented; the caregiver states, “My daughter has been coughing the past few days, and it worsens at night. She is exhausted and cannot sleep.” Eyes noted to be reddened, watery, clear rhinorrhea. Heart sounds S1, S2, peripheral pulses +3, skin hot, dry, wheezing auscultated bilaterally on expiration, harsh raspy sounding, nonproductive cough, bowel sounds normoactive x4 quadrants. Temperature 101.2°F (38.4°C), heart rate 136, respirations 38, blood pressure 98/58 mmHg, pulse oximetry 97% on room air. Wong-Baker pain scale of 4/10, the client states, “My body hurts.” Question 1 Based on the data gathered from the client’s history and physical, highlight the findings for which the nurse should be concerned. Client alert and oriented; the caregiver states, “My daughter has been coughing the past few days, and it worsens at night. She is exhausted and cannot sleep.” Eyes noted to be reddened, watery, clear rhinorrhea. Heart sounds S1, S2, peripheral pulses +3, skin hot, dry, wheezing auscultated bilaterally on expiration, harsh raspy sounding, nonproductive cough, bowel sounds normoactive x4 quadrants. Temperature 101.2°F (38.4°C), heart rate 136, respirations 38, blood pressure 98/58 mmHg, pulse oximetry 97% on room air. Wong-Baker pain scale of 4/10, the client states, “My body hurts.”
SCIENCE
HEALTH SCIENCE
NURSING

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