A nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse take
Obtain a throat culture.
Visualize the epiglottis with a tongue depressor
Place the child in an upright position
Transport the child to radiology for a throat x-ray
The Correct Answer is C
A. Obtaining a throat culture and B. visualizing the epiglottis with a tongue depressor are not safe actions for the nurse to perform without appropriate medical equipment and expertise. These actions can trigger a sudden airway obstruction in a child with epiglottitis. The priority is to ensure airway patency and seek immediate medical assistance.
C. Place the child in an upright position.
Suspected epiglottitis is a medical emergency that can result in rapid airway obstruction. Placing the child in an upright position helps improve airflow by allowing the throat to open and reduces the risk of complete airway obstruction. It's important not to perform invasive procedures (such as throat culture or visualization of the epiglottis) without proper medical equipment and expertise, as these actions can lead to worsening airway obstruction.
D. Transporting the child to radiology for a throat x-ray is not appropriate in this situation, as it may delay necessary interventions to secure the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "That big soft spot will be covered in bone by the end of the second month" is not accurate. The closure usually occurs later than the second month.
B. "The big soft spot will close at around 24 months of age" is an overestimation of the typical closure time. It is usually closed earlier than 24 months.
C. "The big soft spot is usually closed between 12 and 18 months of age."
The anterior fontanel is the soft spot located on the baby's head, and its closure is a natural part of an infant's development. The timing of closure can vary from one child to another. However, the typical range for the closure of the anterior fontanel is between 12 and 18 months of age. This information provides a general guideline for parents while acknowledging the natural variability in child development.
D. "Babies' soft spots close at different times depending on their growth rate" is true to some extent, but providing a general range (option C) is more informative for parents.
Correct Answer is C
Explanation
A. Varying the child's schedule each day may add unnecessary stress and disrupt the child's sense of routine and stability, which is important during a hospitalization.
B. Providing a daily session with a play therapist may be valuable but does not directly address the child's developmental need for competence and mastery.
C. Encourage the client to complete school work.
Erikson's psychosocial stage theory suggests that children at the age of 10 are in the "Industry vs. Inferiority" stage. During this stage, children strive to develop a sense of competence and mastery in various activities. Encouraging the child to complete school work aligns with this stage, as it fosters a sense of accomplishment, competence, and success, which is crucial for their psychosocial development.
D. Discouraging visits from the client's friends would not support the child's social and emotional well-being during the hospitalization, and social connections are important for psychosocial development.
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