A nurse is planning care for a child who has varicella. Which of the following interventions should the nurse plan to include?

Choice A Reason:

Shrug their shoulders against mild pressure. The accessory nerve controls the movement of the trapezius and sternocleidomastoid muscles. To assess this nerve, the nurse should ask the child to shrug their shoulders against mild resistance or pressure applied by the nurse's hands on the child's shoulders. This action evaluates the strength and symmetry of the trapezius muscles, which are innervated by the accessory nerve.

Choice B Reason:

Move their tongue in all directions. This action assesses the function of the hypoglossal nerve (cranial nerve XII), which controls tongue movement.

Choice C Reason:

Follow a light in the six cardinal positions. This action assesses the function of the extraocular muscles and cranial nerves III, IV, and VI, which control eye movements.

Choice D Reason:

Show their teeth while smiling. This action primarily assesses the facial nerve (cranial nerve VII), which controls facial expressions, including smiling and showing teeth.

Choice A Reason:

Check oxygen saturation every 4 hr.: While monitoring oxygen saturation is important, in acute epiglottitis, continuous monitoring of oxygen saturation is necessary due to the potential for rapid airway compromise. Intermittent checks every 4 hours may not provide timely information about deteriorating respiratory status.

Choice B Reason:

Obtain a throat culture: While obtaining a throat culture can help identify the causative organism, the priority in acute epiglottitis is securing the airway and stabilizing the child's condition. Attempting a throat culture could provoke agitation or worsen the obstruction due to irritation of the swollen epiglottis.

Choice C Reason:

Initiate droplet isolation precautions: This is an important action because acute epiglottitis is often caused by bacteria, such as Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae, which can spread via respiratory droplets. Isolation precautions help prevent the transmission of the infection to others and protect healthcare workers.

Choice D Reason:

Assist the child into the supine position: In acute epiglottitis, positioning the child supine (lying flat on the back) can worsen the airway obstruction. Keeping the child calm and in a comfortable position that allows easier breathing is important. Sitting the child upright or in a position of comfort that facilitates breathing and minimizes airway obstruction is preferred.