A nurse is caring for an adult client.
The nurse should determine the assessment findings are consistent with which of the following disease processes?
For each assessment finding, click to specify if the assessment finding is consistent with laryngotracheobronchitis (LTB), epiglottitis, or foreign body aspiration. Each finding may support more than 1 disease process.
Respiratory rate
Irritability
Drooling
Fever
Immunization status
The Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,B,C"},"C":{"answers":"B,C"},"D":{"answers":"A,B"},"E":{"answers":"B"}}
- Respiratory Rate: LTB, Epiglottitis, Foreign Body Aspiration. An increased respiratory rate (tachypnea) is common in both conditions due to airway obstruction and respiratory distress. In epiglottitis, inflammation and swelling of the epiglottis severely restrict airflow, leading to tachypnea. Similarly, foreign body aspiration can cause partial obstruction, increasing respiratory effort and rate. Increased respiratory rate is a significant finding in LTB due to airway narrowing and respiratory distress. The body compensates for the partial airway obstruction by increasing ventilation. However, tachypnea in LTB is usually not as severe as in epiglottitis or foreign body aspiration, where airway obstruction is more critical.
- Irritability: LTB, Epiglottitis, Foreign Body Aspiration. Irritability is a common symptom in all three conditions due to hypoxia and respiratory distress. In LTB (croup), inflammation leads to airway narrowing, causing discomfort and restlessness. In epiglottitis, the rapid onset of airway swelling results in agitation. Foreign body aspiration also causes significant distress due to the sudden obstruction of airflow.
- Drooling: Epiglottitis, Foreign Body Aspiration. Drooling is characteristic of epiglottitis because the client cannot swallow due to severe throat pain and airway swelling. It is also seen in foreign body aspiration when an object is lodged in the airway or esophagus, making swallowing difficult. Drooling is not a typical feature of LTB, where coughing and stridor are more prominent.
- Fever: LTB, Epiglottitis. Both LTB and epiglottitis are caused by infections and present with fever. In LTB, viral infections like parainfluenza commonly cause a low-to-moderate fever. Epiglottitis, often caused by bacterial infections such as Haemophilus influenzae type B (Hib), typically presents with a high fever, as seen in this case. Foreign body aspiration is not associated with fever unless secondary infection develops.
- Immunization Status: Epiglottitis. Epiglottitis is strongly linked to Haemophilus influenzae type B (Hib), a bacteria preventable by routine childhood vaccination. In unvaccinated individuals or those with incomplete immunization, epiglottitis is more likely to occur. Immunization status does not directly correlate with LTB (which is viral) or foreign body aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Standard: While a standard resume format includes basic information about education and experience, it may not effectively address the nurse's multiple moves and varied positions, potentially raising concerns about stability and commitment.
B. Functional: This resume type is most appropriate for the nurse in this situation as it focuses on skills and experiences rather than a chronological work history. This format allows the nurse to highlight relevant skills gained in different positions without emphasizing the frequent changes in employment, which could be beneficial in presenting a cohesive professional narrative.
C. Sequence: This term is less commonly used in resume types and may not provide clarity in presenting qualifications or experiences.
D. Chronological: While this format lists experiences in reverse chronological order, it may draw attention to the frequent changes in positions and locations, which could raise red flags for potential employers regarding the nurse's commitment and stability in a job.
Correct Answer is D
Explanation
A. Develop a quality improvement program for nurses involved in medication administration errors. While quality improvement programs are essential, implementing a targeted program without first analyzing the root causes of errors may not effectively address the underlying issues. A broader review of system-wide factors contributing to medication errors is necessary before designing an intervention.
B. Require staff nurses to demonstrate competency by passing a medication administration examination. Competency assessments may help identify knowledge gaps, but they do not address system-based errors such as workload issues, unclear protocols, or distractions during medication administration. A root cause analysis should be conducted first to ensure that interventions target the actual sources of errors.
C. Provide an inservice on medication administration to all the nurses. Educational sessions can reinforce safe practices, but without identifying the specific factors contributing to errors, they may not be effective. Training should be tailored to address the findings from an initial review of the medication errors.
D. Review the events leading up to each medication administration error. The first step in continuous quality improvement is conducting a thorough analysis of the errors, identifying patterns, and determining root causes. This helps in designing targeted interventions, whether they involve process changes, additional training, or improved safety protocols.
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