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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
A. Corticosteroids help reduce airway inflammation during an asthma exacerbation, which can help improve breathing and reduce symptoms.
D. Bronchodilator medications, such as albuterol, help relax the muscles around the airways, making it easier to breathe during an asthma exacerbation. They are typically used as rescue medications to provide immediate relief of asthma symptoms.
B. Placing the client in a supine position (lying flat on their back) is not recommended during an asthma exacerbation. This position can make breathing more difficult for someone experiencing respiratory distress.
C. Vigorous physical activity can exacerbate asthma symptoms and trigger an asthma attack. During an asthma exacerbation, it's important to encourage the client to rest and avoid strenuous activities that could worsen their breathing difficulties.
E. Cold compresses are not recommended for asthma exacerbations. Warm, moist air may help loosen mucus and ease breathing, but cold compresses could potentially exacerbate symptoms or discomfort.
Correct Answer is C
Explanation
C. The Eustachian tube in infants is shorter, straighter, and wider compared to adults. This anatomy makes it easier for bacteria or viruses from the nasopharynx to travel up the Eustachian tube and infect the middle ear, contributing to the increased susceptibility to otitis media.
A. Infants spend a significant amount of time lying down, whether in a supine (on their backs) or prone (on their stomachs) position. However, this does not increase the risk of otitis media
B. Sucking on a nipple does create pressure changes in the middle ear but it's not the primary reason infants are more susceptible to otitis media.
D. Sucking on a nipple does create pressure changes in the middle ear but it's not the primary reason infants are more susceptible to otitis media
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