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.
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Correct Answer is C
Explanation
Option A (Place the infant in reverse Trendelenburg position) and option B (Place the infant in the knee to chest position) are not the immediate actions to address this situation. While these positions might be used in specific situations, assessing blood pressure is more appropriate in this context to evaluate for potential vascular issues.
Option C. Take the infant's blood pressure in all extremities.
In an infant with weaker femoral pulses compared to the brachial and radial pulses, there might be a concern about coarctation of the aorta (a narrowing of the aorta), which can affect blood flow to the lower extremities. To confirm this and assess for potential issues, taking blood pressure measurements in all four extremities is crucial. This comparison can help identify pressure differentials between the upper and lower extremities, which is a hallmark sign of coarctation of the aorta.
Option D (Notify the Physician) is generally a good step, but taking the blood pressure in all extremities should be done first to provide comprehensive information for the physician when discussing the infant's condition.
Correct Answer is D
Explanation
A. Diabetes Insipidus is associated with reduced ADH levels, leading to excessive urination and dehydration, not hyponatremia.
B. Acromegaly results from excessive growth hormone (not ADH) secretion, causing abnormal growth of tissues and bones.
C. Addison's disease involves the adrenal glands and the insufficient production of cortisol and aldosterone, not ADH-related hyponatremia.
D. Syndrome of Inappropriate Antidiuretic Hormone (SIADH).
SIADH is a disorder characterized by the excessive release of antidiuretic hormone (ADH) from the posterior pituitary gland, leading to increased water reabsorption by the kidneys. This results in diluted blood and hyponatremia (low sodium levels) due to the retention of water. Patients with SIADH often experience fluid overload and related symptoms.
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