The nurse is assessing a child with epiglottitis in the emergency department. The child has a sore throat and is drooling. Examining the child's throat using a tongue depressor might precipitate which of the following?
Respiratory tract infection
Sore throat
Complete airway obstruction
Inspiratory stridor
The Correct Answer is C
Choice A reason: Respiratory tract infection is not a correct answer because it is not a complication of examining the child's throat. It is a possible cause of epiglottitis, which is an inflammation of the epiglottis, the flap that covers the entrance to the trachea.
Choice B reason: Sore throat is not a correct answer because it is not a complication of examining the child's throat. It is a symptom of epiglottitis, along with fever, difficulty swallowing, and drooling.
Choice C reason: Complete airway obstruction is the correct answer because it is a life-threatening complication of examining the child's throat. The tongue depressor can trigger a spasm of the epiglottis, which can block the airway and cause respiratory distress or arrest.
Choice D reason: Inspiratory stridor is not a correct answer because it is not a complication of examining the child's throat. It is a sign of upper airway obstruction, which can occur in epiglottitis, but it is not caused by the tongue depressor.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is not a good intervention because it disregards the parent's and the child's religious beliefs and values. It may also imply that the nurse knows better than the parent what is best for the child.
Choice B reason: This is not a necessary intervention because it does not address the immediate issue of the child's nutrition. It may also suggest that the nurse thinks the parent needs spiritual guidance or counseling.
Choice C reason: This is not a respectful intervention because it violates the parent's and the child's right to follow their dietary rules. It may also cause the parent and the child to feel guilty or conflicted.
Choice D reason: This is the best intervention because it honors the parent's and the child's preferences and practices. It also ensures that the child receives adequate and appropriate nutrition.
Correct Answer is D
Explanation
Choice A reason: The child's current vital signs are consistent with vital signs over the past 4 hours. This does not indicate that the child is in pain, as the vital signs may be within normal range or stable.
Choice B reason: The child becomes quiet when held and cuddled. This may indicate that the child is comforted by the nurse's presence and touch, not that the child is in pain.
Choice C reason: The child has just returned from the recovery room. This may indicate that the child is still under the influence of anesthesia or sedation, not that the child is in pain.
Choice D reason: The child is lying rigidly in bed and not moving. This is a sign of pain in children, as they may try to avoid movement or stimulation that could worsen their pain. The nurse should assess the child's pain level and administer pain medication as prescribed.
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