A nurse is planning care for a child who has epiglottitis. Which of the following actions should the nurse plan to take?

Obtain a throat culture.

Visualize the epiglottis using a tongue depressor.

Provide moist air to reduce the inflammation of the epiglottis

Initiate airborne precautions.

Answer and Explanation

The Correct Answer is C

A. Obtain a throat culture.

This option is not appropriate as a primary nursing action in the acute management of epiglottitis. While obtaining a throat culture may be necessary for diagnostic purposes, it is not a priority in the immediate care of a child with suspected epiglottitis. The focus should be on ensuring airway patency and providing emergency treatment.

B. Visualize the epiglottis using a tongue depressor.

This option is contraindicated in the acute management of epiglottitis. Direct visualization of the epiglottis using a tongue depressor or other instruments can provoke spasm of the epiglottis and worsen airway obstruction. Attempting to visualize the epiglottis should be avoided until the child's airway has been secured in a controlled environment, such as in the operating room under anesthesia.

C. Provide moist air to reduce the inflammation of the epiglottis.

This option is appropriate. Providing moist air, such as humidified oxygen or a cool mist, can help soothe the inflamed tissues of the epiglottis and upper airway. Moist air may help alleviate discomfort and reduce inflammation, although it will not directly address the risk of airway obstruction. It is often used as supportive therapy in conjunction with other interventions.

D. Initiate airborne precautions.

This option is not necessary for the care of a child with epiglottitis. Epiglottitis is not typically transmitted through airborne droplets. The priority in the management of epiglottitis is ensuring a patent airway and providing appropriate treatment to reduce inflammation and prevent complications.

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Correct Answer is C

Explanation

A. Administer the medication at mealtime.Ferrous sulfate is best absorbed on an empty stomach because food, especially those rich in calcium or tannins, can interfere with its absorption. Administering it with meals reduces its effectiveness.

B.While bedtime administration is not contraindicated, it is not necessary. The timing of administration should focus on maximizing absorption, typically between meals or on an empty stomach.

C. Ferrous sulfate can stain teeth if taken orally in liquid form. Using a straw minimizes contact with teeth, reducing the risk of discoloration. Parents should also be advised to encourage the child to rinse their mouth after taking the medication.

D. Dilute the medication with 240 mL of milk. Milk contains calcium, which inhibits the absorption of iron. Ferrous sulfate should not be taken with milk or dairy products to ensure optimal absorption.

A. Flaccid paralysis of lower extremities B. Hip dislocation C. Hydrocephalus D. Dimple in sacral area

Correct Answer is D

Explanation

A. Flaccid paralysis of lower extremities:

Flaccid paralysis refers to a weakness or loss of muscle tone in the affected muscles, leading to decreased or absent movement. This finding is not typically associated with spina bifida occulta. Instead, it is more commonly seen in more severe forms of spina bifida, such as myelomeningocele, where there is significant involvement of the spinal cord and nerves.

B. Hip dislocation:

Hip dislocation can occur in individuals with myelomeningocele due to muscle weakness, abnormal muscle tone, and joint deformities associated with spinal cord defects. However, it is not typically associated with spina bifida occulta, which usually presents with less severe spinal cord involvement.

C. Hydrocephalus:

Hydrocephalus, characterized by the accumulation of cerebrospinal fluid within the brain, is a common complication of myelomeningocele due to disturbances in the flow and absorption of cerebrospinal fluid caused by the spinal defect. It is less commonly associated with spina bifida occulta, which typically involves a less severe spinal cord defect.

D. Dimple in sacral area:

This is the correct choice. A dimple, patch of hair, or birthmark in the lower back or sacral area is a common finding in spina bifida occulta. It occurs due to the incomplete closure of the spinal column during fetal development, leading to a small defect in the vertebrae. This is often a subtle manifestation of spina bifida occulta and may not cause significant symptoms or functional impairment.

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A nurse is planning care for a child who has epiglottitis. Which of the following actions should the nurse plan to take?

Nursing Test Bank

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