The nurse in the emergency department is caring for a child who appears extremely ill with a high fever, unable to control their oral secretions. with voice hoarseness and inspiratory stridor and inspiratory sternal retractions while breathing. The nurse suspects epiglottitis. Which would the nurse do next?
Contact the assigned emergency room physician to evaluate the need for an advanced airway
Administer intravenous corticosteroids
Obtain a throat culture
inspect the throat to obtain further data to support the diagnosis
The Correct Answer is A
A. Contact the assigned emergency room physician to evaluate the need for an advanced airway
Explanation:
Epiglottitis is a medical emergency that can rapidly progress to airway obstruction. The classic signs and symptoms include a high fever, difficulty swallowing, voice hoarseness, inspiratory stridor, and sternal retractions. Immediate intervention may be necessary to secure the airway. Therefore, contacting the emergency room physician to evaluate the need for an advanced airway (such as intubation) is a priority.
B. Administer intravenous corticosteroids
Explanation: While corticosteroids may be used in the management of epiglottitis to reduce airway inflammation, securing the airway is the priority in the acute phase. Corticosteroids would typically be administered after securing the airway.
C. Obtain a throat culture
Explanation: Obtaining a throat culture is not the immediate priority in the case of suspected epiglottitis. Prompt intervention to secure the airway takes precedence over diagnostic tests.
D. Inspect the throat to obtain further data to support the diagnosis
Explanation: Direct visualization of the throat (inspection) may exacerbate the airway obstruction and is not recommended in the acute management of suspected epiglottitis. The priority is to secure the airway while minimizing agitation and discomfort for the child. Diagnostic procedures, such as obtaining a throat culture, can be considered after the airway is stabilized.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. The child needs to avoid exposure to other illnesses.
Explanation: Children with AIDS have compromised immune systems and are more susceptible to infections. Therefore, it is important to minimize exposure to other illnesses to reduce the risk of infections.
B. Frequent handwashing is important.
Explanation: Good hand hygiene helps prevent the spread of infections. Encouraging frequent handwashing is crucial in the care of a child with AIDS.
C. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach).
Explanation: Using a bleach solution to clean up body fluid spills helps to disinfect and reduce the risk of transmission of infections. The recommended ratio is 10 parts water to 1 part bleach.
D. Monitor the child's weight.
Explanation: Monitoring the child's weight is important for assessing nutritional status and overall health. Weight loss may indicate underlying health issues that need attention.
E. The child's immunization schedule will need revision.
Explanation: Children with AIDS may have altered immune function, but the need for immunizations is still crucial. However, live vaccines may need to be avoided. The immunization schedule should be discussed and individualized with the healthcare provider.
F. Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention.
Explanation: While these symptoms may occur, they should not be dismissed without evaluation. Any changes in the child's health, including symptoms such as fever, malaise, fatigue, weight loss, vomiting, and diarrhea, should be reported to the healthcare provider for appropriate assessment and intervention.
Correct Answer is B
Explanation
A. Use a padded tongue blade:
Incorrect: Inserting anything into the child's mouth, including a padded tongue blade, is not recommended during a seizure. It can lead to oral and airway injuries. It's important to keep the airway clear, but this is achieved by positioning the child laterally.
B. Position the child laterally.
Correct Answer: This is the correct action. Placing the child on their side helps prevent aspiration of fluids and promotes a clear airway during the seizure. It also reduces the risk of injury.
C. Restrain the child's arms:
Incorrect: Restraining the child's arms can increase the risk of injury and is not recommended during a seizure. It's crucial to ensure a safe environment and prevent injury, but physically restraining the child is not the appropriate approach.
D. Attempt to stop the seizure:
Incorrect: It is not within the nurse's capacity to immediately stop a seizure. Seizures are neurological events, and they need to run their course. The focus should be on ensuring the safety of the child during the seizure.
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