The nurse employed in an emergency department is instructed to monitor a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. The nurse interprets this observation as indicating which finding?
Extreme fatigue
An airway obstruction
The presence of dehydration
The presence of pain
The Correct Answer is B
B. Leaning forward with the chin thrust out, often described as the "sniffing position," is a classic sign of airway obstruction, particularly in cases of epiglottitis. This positioning helps to maximize airway patency by opening the airway and reducing the risk of further obstruction.
A. Leaning forward with the chin thrust out is not typically associated with extreme fatigue. Instead, it is a specific positioning often seen in individuals with epiglottitis to help alleviate airway obstruction and facilitate breathing.
C. Leaning forward with the chin thrust out is not indicative of dehydration. Dehydration may present with other signs and symptoms such as dry mucous membranes, decreased urine output, sunken fontanelle (in infants), and poor skin turgor.
D. Pain may be present in a child with epiglottitis but leaning forward with the chin thrust out is not primarily indicative of pain. This positioning is primarily a compensatory mechanism to alleviate airway obstruction rather than a response to pain.
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Related Questions
Correct Answer is D
Explanation
D The forward bending test, also known as the Adam's forward bend test, is commonly used to screen for idiopathic scoliosis. During this test, the child is instructed to bend forward from the waist with their arms hanging downward and palms touching or overlapping. This position allows the nurse to observe the child's back for asymmetry, rib humps, or other signs of spinal curvature characteristic of scoliosis.
A This position may be used for certain examinations, such as assessing the spine's curvature but it is not typically the position used for screening for idiopathic scoliosis.
B This instruction involves cervical spine movement and is not relevant to screening for idiopathic scoliosis. It may be part of a different examination, such as assessing cervical spine range of motion or neurological function, but it does not aid in detecting scoliosis.
C Turning to the side and remaining relaxed may not provide adequate visualization of the spine's curvature, which is essential for scoliosis screening. Additionally, this position does not allow for proper assessment of the spine's alignment.
Correct Answer is D
Explanation
D. Place resuscitation equipment at the child's bedside. This is because epiglottitis can lead to a life- threatening emergency requiring immediate intervention, and having resuscitation equipment readily available is essential for rapid response.
A. Establishing intravenous access may be necessary for administering fluids and medications but it is not the nurse's priority action when caring for a child with suspected epiglottitis.
B. Droplet precautions help reduce the risk of transmission of respiratory pathogens to others. However, the priority is to address the child's respiratory distress and potential airway compromise.
C. Providing blow-by humidified oxygen can be beneficial in managing the child's respiratory status. However, securing the airway takes precedence over other interventions, as indicated by the guidelines for managing epiglottitis.
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