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Common Pediatric Conditions
Study Questions
Croup
A 2-year-old boy is brought to the emergency department with a barking cough, hoarseness, and inspiratory stridor.
His parents report that he has been sick for 2 days and that his symptoms have been getting worse.
The boy's vital signs are as follows: temperature 102°F (38.9°C), heart rate 120 beats/minute, respiratory rate 28 breaths/minute, and oxygen saturation 95% on room air.
Physical examination reveals a well-developed, well-nourished boy in moderate respiratory distress.
He is using accessory muscles of respiration and has intercostal retractions.
His lungs are clear to auscultation.
Which of the following statements by the nurse is most appropriate?
Explanation
The correct answer is choice A, “Your son has croup.”
Choice A rationale:
The symptoms described, including a barking cough, hoarseness, and inspiratory stridor, are classic signs of croup. Croup is a common respiratory condition in young children that leads to swelling of the larynx and trachea, causing the characteristic cough and stridor.
Choice B rationale:
While epiglottitis can present with respiratory distress, it is more commonly associated with high fever, severe sore throat, drooling, and difficulty swallowing, rather than a barking cough and stridor.
Choice C rationale:
Asthma typically presents with wheezing and difficulty exhaling, not the barking cough and inspiratory stridor seen in croup. Additionally, asthma is often associated with a history of allergies or atopic conditions, which are not mentioned in the scenario.
Choice D rationale:
Pneumonia usually presents with fever, cough producing phlegm, and crackles or wheezes on lung auscultation. The clear lungs on auscultation and the absence of productive cough make pneumonia less likely in this case.
In summary, the presentation of a barking cough, hoarseness, and inspiratory stridor in a young child who is in moderate respiratory distress with a recent onset of symptoms is most indicative of croup. This is supported by the age of the child and the clinical findings, which align with the typical presentation of croup.
Which clinical manifestations should the nurse include in the teaching? Select all that apply.
Explanation
Choice A rationale:
High fever is not a typical symptom of croup.
Croup is often caused by viral infections, and high fever is more commonly associated with bacterial infections.
This choice is incorrect.
Choice B rationale:
Inspiratory stridor is a classic symptom of croup and is caused by the narrowing of the larynx and trachea, leading to a high-pitched sound during inspiration.
This choice is correct.
Choice C rationale:
A barking cough is a distinctive symptom of croup and is caused by inflammation of the larynx and trachea.
This choice is correct.
Choice D rationale:
Wheezing is not a typical symptom of croup.
Wheezing is more commonly associated with conditions like asthma, where there is narrowing of the smaller airways (bronchioles).
This choice is incorrect.
Choice E rationale:
Respiratory distress, indicated by increased work of breathing, is a common symptom of croup.
It can manifest as the use of accessory muscles, intercostal retractions, and nasal flaring.
This choice is correct.
What should the nurse assess to determine the severity of respiratory distress?
Explanation
The nurse should assess the degree of airway obstruction to determine the severity of respiratory distress.
Choice A rationale:
Assessing the child's height and weight is important for overall health assessment but does not specifically determine the severity of respiratory distress in croup.
Respiratory distress is primarily evaluated by assessing airway patency, effort of breathing, and oxygenation.
Choice B rationale:
The child's vaccination history is crucial for preventing certain infectious diseases, but it does not directly assess the severity of respiratory distress in croup.
Croup is commonly caused by viral infections such as parainfluenza viruses.
Choice C rationale:
Assessing the degree of airway obstruction is essential in determining the severity of respiratory distress in croup.
Children with croup often present with stridor, a high-pitched sound heard during inspiration, indicating partial airway obstruction.
The severity of stridor, along with signs of increased work of breathing, provides valuable information about the child's respiratory status.
Choice D rationale:
The child's social activities are not directly related to the assessment of respiratory distress in croup.
While social history is important in a comprehensive nursing assessment, it does not provide specific information about the severity of airway obstruction in croup.
What interventions are appropriate for a child with croup? Select all that apply.
Explanation
Nursing interventions for a child with croup include providing cool mist humidification, administering bronchodilators, and administering corticosteroids.
Choice A rationale:
Administering antibiotics is not a standard intervention for croup unless there is a secondary bacterial infection present.
Croup is typically caused by viral infections, so antiviral medications might be considered if the cause is identified as a specific virus.
However, antibiotics do not directly address the symptoms of croup.
Choice B rationale:
Providing cool mist humidification is appropriate for a child with croup.
Cool mist helps soothe the inflamed airways and can alleviate respiratory distress by reducing airway edema.
Moist air can make breathing easier for the child.
Choice C rationale:
Administering bronchodilators can be beneficial in the treatment of croup, especially if there is evidence of bronchoconstriction.
Bronchodilators help dilate the airways, making breathing easier for the child.
This intervention can be particularly useful if the child is experiencing wheezing in addition to stridor.
Choice D rationale:
Administering corticosteroids, such as dexamethasone, is a common and evidence-based intervention for croup.
Corticosteroids reduce airway inflammation and edema, leading to symptom improvement.
A single dose of oral corticosteroids is often sufficient to manage croup symptoms effectively.
Choice E rationale:
Encouraging the child to cough loudly is not a recommended intervention for croup.
Coughing forcefully may exacerbate airway irritation and inflammation, worsening the child's symptoms.
Instead, interventions should focus on reducing airway edema and providing respiratory support.
The child's mother states that the child has had a barking cough for 2 days, which is worse at night.
The child also has a fever and is hoarse.
Which of the following statements by the nurse is most appropriate?
Explanation
The nurse should assess the child's vital signs and listen to his lungs.
Choice A rationale:
Assessing vital signs, including heart rate, respiratory rate, oxygen saturation, and temperature, is essential in evaluating the child's overall condition and the severity of respiratory distress.
Listening to the child's lungs can help identify abnormal breath sounds, such as stridor or wheezing, which are common in croup.
This information guides further interventions and helps determine the appropriate level of care.
Choice B rationale:
While croup can cause respiratory distress, not every case requires an emergency room visit.
The severity of symptoms, including the child's ability to breathe and oxygenate, should guide the decision to seek emergency care.
In this scenario, assessing vital signs and lung sounds is the initial appropriate action.
Choice C rationale:
Croup is a treatable condition, and there are specific interventions, such as providing humidified air and corticosteroids, that can alleviate symptoms and prevent complications.
It is incorrect to tell the parent that there is nothing that can be done for croup.
Medical intervention can significantly improve the child's condition.
Choice D rationale:
Croup is primarily caused by viral infections, not bacterial infections.
Administering antibiotics without confirming a bacterial infection is inappropriate and contributes to antibiotic resistance.
The nurse explains that croup is a viral infection that causes inflammation of the upper airway.
The nurse also explains that the most common symptoms of croup are a barking cough, hoarseness, and stridor.
Which of the following statements by the client indicates that they understand the nurse's explanation?
Explanation
Choice A rationale:
This statement does not indicate a complete understanding of croup.
Croup is not just a cold that affects the throat; it specifically involves inflammation of the upper airway.
Choice B rationale:
This statement acknowledges that croup can be serious but usually resolves on its own.
While this is true, it does not encompass the key symptoms and actions the parent should take if the child's condition worsens.
Choice C rationale:
This statement addresses general cold symptoms but does not specifically mention the characteristic symptoms of croup, such as barking cough, hoarseness, and stridor.
Choice D rationale:
This is The correct answer.
It shows an understanding of the symptoms of croup, particularly the mention of having trouble breathing, which is a sign of severe croup that requires medical attention.
Parents should seek emergency medical care if their child experiences difficulty breathing due to croup.
Providing this information demonstrates a comprehensive understanding of the condition.
Which of the following are nursing interventions for a child with croup?
Explanation
Choice A rationale:
Administering oxygen therapy is essential in cases of severe croup where the child has difficulty breathing.
Oxygen therapy helps ensure adequate oxygenation, which is crucial in managing respiratory distress.
Choice B rationale:
Positioning the child upright facilitates breathing by allowing the airways to remain open and reducing airway obstruction.
This position helps alleviate symptoms like stridor and allows the child to breathe more comfortably.
Choice C rationale:
Providing humidified air helps loosen secretions and makes it easier for the child to breathe.
Humidification can reduce airway irritation and soothe the inflamed throat, providing relief from croup symptoms.
Choice D rationale:
This choice is incorrect because encouraging the child to drink plenty of fluids is generally good advice for any illness but is not specific to croup.
While it is essential to keep the child hydrated, it is not a direct nursing intervention for managing croup symptoms.
Choice E rationale:
Monitoring the child's respiratory status closely is crucial in assessing the effectiveness of the interventions and identifying any signs of respiratory distress.
Close monitoring allows nurses to make timely decisions and take appropriate actions to maintain the child's respiratory function.
The nurse explains that it is important to keep the child hydrated and to provide humidified air.
Which of the following statements by the parent indicates that they understand the nurse's instructions?
Explanation
Choice A rationale:
While giving the child plenty of water and juice is important for hydration, this statement does not address the specific management of croup symptoms.
Choice B rationale:
Running a hot shower and letting the child sit in the bathroom can create a steamy environment, but it is not the most effective way to provide humidified air.
A cool mist humidifier is a more controlled and efficient method for delivering humidified air to the child.
Choice C rationale:
This is The correct answer.
Using a cool mist humidifier in the child's bedroom is an appropriate way to provide humidified air, which can help ease breathing difficulties associated with croup.
Cool mist humidifiers add moisture to the air without heating it, making it easier for the child to breathe and reducing throat irritation.
Choice D rationale:
Giving the child a warm bath may provide some comfort but does not specifically address the need for humidified air, which is crucial in managing croup symptoms.
Providing humidified air helps soothe the inflamed airways and reduce respiratory distress associated with croup.
The child's respiratory status is worsening, and they are becoming increasingly agitated.
What action should the nurse take?
Explanation
Choice A rationale:
Continuing to monitor the child's respiratory status may not be the best action in this situation, as the child's respiratory status is worsening and they are becoming increasingly agitated.
Immediate intervention is required to alleviate the child's distress.
Choice B rationale:
Administering oxygen therapy as needed is a supportive measure in respiratory distress situations, but in the case of severe croup with worsening respiratory status and agitation, nebulized epinephrine is the treatment of choice to reduce airway inflammation and improve breathing.
Choice C rationale:
Nebulized epinephrine is the primary treatment for severe croup as it helps reduce upper airway edema, relieve stridor, and improve respiratory distress.
It acts by causing vasoconstriction, which reduces swelling in the upper airway, making breathing easier for the child.
Therefore, preparing to administer nebulized epinephrine is the most appropriate action in this situation.
Choice D rationale:
Notifying the physician immediately is essential, but immediate intervention to improve the child's respiratory distress is also necessary.
Nebulized epinephrine should be administered promptly to alleviate the child's symptoms and prevent further deterioration.
The child's oxygen saturation is 92%.
The nurse assesses the child's respiratory status and determines that the child has moderate croup.
Which of the following statements by the nurse is most appropriate?
Explanation
Choice A rationale:
Placing the child on a ventilator might be necessary in severe cases of croup, but it should not be the first action taken.
In this scenario, the child has moderate croup, so less invasive interventions should be attempted first.
Choice B rationale:
Administering medication to help the child's cough and breathing is an appropriate first step in managing moderate croup.
Nebulized epinephrine or corticosteroids are commonly used to reduce airway inflammation and relieve respiratory distress in croup.
This intervention can be effective in improving the child's symptoms and overall condition.
Choice C rationale:
Transferring the child to the ICU for closer monitoring is not immediately necessary in this case of moderate croup.
Such a step might be considered if the child's condition worsens despite initial interventions or if there are signs of severe respiratory distress.
Choice D rationale:
Discharging the child home without appropriate treatment and monitoring would be unsafe, given the child's symptoms and oxygen saturation level.
Immediate intervention and observation are required to ensure the child's respiratory status improves.
Which of the following statements should the nurse include in the teaching?
Select all that apply.
Explanation
Choice A rationale:
Croup is indeed a common viral infection of the upper respiratory tract that causes inflammation of the larynx.
This statement is accurate and important for the parent to understand the nature of the illness.
Choice B rationale:
Croup is most common in children under the age of 5, not just under the age of 3.
However, this statement is not entirely accurate, as older children can also be affected by croup.
It is essential to provide correct information to the parent.
Choice C rationale:
The symptoms of croup often worsen at night due to the natural narrowing of the airways during sleep, making breathing more difficult.
Therefore, this statement is correct and relevant to include in the teaching.
Choice D rationale:
The classic croup cough is indeed described as a barking cough, which results from the inflammation of the larynx and trachea.
This description helps the parent recognize a distinctive symptom of croup.
Including this information in the teaching is appropriate.
Choice E rationale:
Croup is primarily managed with supportive care, such as humidified air and nebulized medications.
Over-the-counter cough syrup and expectorants are not typically recommended for treating croup in children.
This statement is incorrect and should not be included in the teaching.
The child is receiving humidified air and nebulized racemic epinephrine.
The nurse monitors the child's respiratory status closely.
Which of the following findings would indicate to the nurse that the child's condition is worsening?
Explanation
Choice A rationale:
An oxygen saturation level of 95% is within the normal range (normal range is typically 95-100%).
While it is essential to monitor oxygen saturation, this value does not indicate worsening of the child's condition.
Choice B rationale:
A respiratory rate of 30 breaths per minute is above the normal range for a child and can indicate respiratory distress.
An increased respiratory rate is a concerning sign, suggesting the child is having difficulty breathing.
This finding indicates the child's condition is worsening and requires prompt attention.
Choice C rationale:
Mild retractions suggest that the child is working harder to breathe but may not necessarily indicate a severe worsening of the condition.
Retractions are a sign of increased respiratory effort but may vary in severity.
Choice D rationale:
A child with croup experiencing severe respiratory distress may not be able to speak in complete sentences due to the difficulty in breathing.
However, the ability to speak in complete sentences alone may not be a definitive indicator of worsening.
Monitoring the respiratory rate and effort is crucial in assessing the child's condition accurately.
Which of the following statements should the nurse include in the teaching?
Explanation
Choice A rationale:
There is no vaccine to prevent croup, but practicing good hand hygiene and avoiding contact with sick people can help reduce the child's risk of getting croup.
Croup is mainly caused by viral infections, so minimizing exposure to viruses is essential in prevention.
Choice B rationale:
Giving a daily dose of vitamin C is not a proven method for preventing croup.
While vitamin C is essential for overall health, it does not specifically prevent croup.
Providing accurate and evidence-based information is crucial in parental education.
Choice C rationale:
Keeping the child's bedroom cool and humid may provide comfort during the illness, but it is not a proven method for preventing croup.
This statement does not contribute significantly to preventive measures against croup.
Choice D rationale:
Using a humidifier in the home can help maintain adequate humidity levels, which may reduce the risk of croup, especially during dry seasons.
Proper humidity can prevent irritation of the upper respiratory tract and decrease the likelihood of developing croup.
Including this information in the teaching is appropriate and beneficial for the parent to know.
Tonsillitis in children.
She explains that tonsillitis is a common condition in children and can be caused by various factors.
One of the parents asks about the causes of tonsillitis.
Which of the following statements by the nurse would be most accurate?
Explanation
Choice A rationale:
Tonsillitis is not always caused by bacterial infections.
It can also be caused by viral infections.
Choice B rationale:
Tonsillitis is not only caused by viral infections.
Bacterial infections can also lead to tonsillitis.
Choice C rationale:
Tonsillitis can be caused by either viral infections such as adenovirus, rhinovirus, or Epstein-Barr virus, or bacterial infections, particularly Streptococcus pyogenes.
This is the most accurate statement.
Streptococcus pyogenes is a common bacterial cause of tonsillitis, and viral infections can also lead to this condition.
Choice D rationale:
Tonsillitis is not usually caused by allergies.
While allergies can cause throat discomfort, they are not a common cause of tonsillitis.
She asks the nurse why her child keeps getting tonsillitis.
Which of the following responses by the nurse would be most appropriate?
Explanation
Choice A rationale:
Enlarged tonsils might contribute to recurrent tonsillitis, but it is not the primary cause.
Choice B rationale:
Dust and irritants can irritate the throat, but they are not the main reason for recurring tonsillitis.
Choice C rationale:
Your child’s immune system might be deficient, making them more susceptible to infections.
This response is appropriate because a weakened immune system can make a child more prone to recurrent infections, including tonsillitis.
Choice D rationale:
Improper handwashing can lead to various infections, but it is not specifically linked to tonsillitis.
The nurse suspects tonsillitis and knows that certain signs and symptoms are indicative of this condition.
Which of the following should the nurse consider? (Select all that apply).
Explanation
Choice A rationale:
The child has been having difficulty swallowing.
Difficulty swallowing is a common symptom of tonsillitis.
Inflamed tonsils can make swallowing painful and difficult.
Choice B rationale:
The child has been experiencing ear pain.
While ear pain can be associated with throat infections, it is not a direct symptom of tonsillitis.
Choice C rationale:
The child has a rash on their arms and legs.
A rash is not a typical symptom of tonsillitis.
It could indicate other conditions such as an allergic reaction or viral illness.
Choice D rationale:
The child’s tonsils appear red and swollen.
Red and swollen tonsils are characteristic signs of tonsillitis.
Inflammation of the tonsils is a key indicator of the condition.
Choice E rationale:
The child has been experiencing frequent nosebleeds.
Nosebleeds are not typically associated with tonsillitis.
They could be due to other factors such as dry air or nasal irritation.
She mentions that in bacterial tonsillitis, certain processes occur within the body.
Which of the following statements best describes these processes?
Explanation
Choice A rationale:
Bacterial tonsillitis is caused by the colonization of bacteria on the tonsils, triggering an immune response.
When bacteria, often Streptococcus species, invade the tonsils, the body's immune system recognizes them as foreign invaders.
This recognition prompts an immune response, leading to inflammation and swelling of the tonsils.
The immune system releases white blood cells and other substances to fight the infection, causing the characteristic symptoms of tonsillitis, such as sore throat, difficulty swallowing, and fever.
This process is a localized immune response specific to the tonsils and their surrounding tissues.
Choice B rationale:
This choice is incorrect because bacteria do not invade the tonsils directly and immediately cause inflammation and swelling.
The immune response is triggered upon recognition of the bacteria, leading to the inflammation and swelling of the tonsils.
Choice C rationale:
This choice is incorrect because bacterial tonsillitis is not caused by an allergic reaction in the tonsils.
It is primarily a result of a bacterial infection, not an allergic response.
Choice D rationale:
This choice is incorrect because bacterial tonsillitis is a localized infection in the tonsils and does not cause a systemic infection that indirectly leads to tonsillitis.
The infection remains localized in the throat area, causing symptoms specific to the tonsils and nearby lymph nodes.
A nurse knows that understanding the etiology of tonsillitis is essential for providing appropriate care to these patients.
Which of the following factors should the nurse consider when assessing this client?
Explanation
Choice A rationale:
When assessing a client with suspected tonsillitis, it is essential to consider whether the client has been exposed to viral or bacterial infections recently.
Tonsillitis can be caused by both viral and bacterial infections, with streptococcal bacteria being a common culprit.
Understanding the type of infection helps healthcare providers determine the appropriate treatment, such as antibiotics for bacterial infections.
Recent exposure to infected individuals or environments increases the likelihood of a contagious infection.
Choice B rationale:
This choice is incorrect because while a balanced diet is crucial for overall health, it is not a direct factor in the etiology of tonsillitis.
Tonsillitis is primarily caused by infections, either viral or bacterial, and is not related to dietary habits.
Choice C rationale:
This choice is incorrect because exposure to cold temperatures is not a direct cause of tonsillitis.
Tonsillitis is caused by infections and is not related to environmental factors like cold weather.
However, cold weather can weaken the immune system, making individuals more susceptible to infections.
Choice D rationale:
This choice is incorrect because recent injuries to the throat area can cause throat pain and discomfort but are not a common cause of tonsillitis.
Tonsillitis is predominantly caused by infections, and injuries play a minor role in its etiology.
The child’s mother reports that the child has been having difficulty swallowing and has had a fever.
Upon examination, the nurse notes that the child’s tonsils are red and swollen, with white patches visible.
The child also has enlarged lymph nodes in the neck.
Which of the following statements by the mother indicates a need for further teaching?
Explanation
Choice A rationale:
Encouraging the child to drink plenty of fluids is a suitable response by the mother.
Staying hydrated is essential to prevent dehydration, especially when the child has difficulty swallowing due to swollen tonsils.
Adequate fluid intake can also soothe the throat and help in the recovery process.
Choice B rationale:
Providing warm soup to soothe the throat is a suitable response.
Warm, soothing liquids can help alleviate throat discomfort and make swallowing easier.
It is a common home remedy for managing sore throat symptoms.
Choice C rationale:
This choice is correct because encouraging the child to cough to clear the throat is not appropriate.
Coughing can irritate the already inflamed tonsils and worsen the sore throat.
Instead, the child should be advised to avoid coughing forcefully, which can aggravate the pain.
Choice D rationale:
Giving the child over-the-counter pain medication as directed is a suitable response.
Over-the-counter pain relievers like acetaminophen or ibuprofen can help reduce pain and fever associated with tonsillitis.
However, it's important to use these medications as directed by a healthcare professional or following the recommended dosage instructions, especially in children.
The nurse observes red and swollen tonsils with white patches, enlarged lymph nodes in the neck, and bad breath.
The client also complains of a headache and abdominal pain.
Which of the following statements by the client indicates an understanding of the care plan?
Explanation
Choice A rationale:
The client's symptoms, including sore throat, difficulty swallowing, fever, red and swollen tonsils with white patches, enlarged lymph nodes, bad breath, headache, and abdominal pain, indicate possible tonsillitis, which is often caused by a bacterial infection.
Rest and increased fluid intake are essential components of the care plan for tonsillitis.
Adequate rest helps the body fight the infection, and increased fluid intake helps prevent dehydration, especially if swallowing is painful.
This choice demonstrates the client's understanding of self-care measures to promote recovery.
Choice B rationale:
Continuing to smoke can worsen the irritation of the throat and prolong the healing process.
Smoking irritates the mucous membranes, making it difficult for the throat to heal.
It can also exacerbate the symptoms and delay recovery.
Choice C rationale:
Tonsillitis caused by bacteria often requires antibiotics to clear the infection completely.
Taking antibiotics only when in pain might lead to incomplete eradication of the bacteria, resulting in a recurrence of the infection or complications.
It is essential to take the full course of antibiotics as prescribed by the healthcare provider.
Choice D rationale:
Going to work when experiencing symptoms of tonsillitis not only jeopardizes the client's health but also puts coworkers at risk of contracting the infection.
Resting at home and avoiding contact with others can prevent the spread of the illness.
The child’s symptoms include a severe sore throat, difficulty swallowing, fever, red and swollen tonsils with white patches, enlarged lymph nodes in the neck, bad breath, headache, abdominal pain, and fatigue.
Select all that apply:.
Explanation
Choice A rationale:
Assessing for drooling is important because severe tonsillitis can cause difficulty swallowing, leading to excessive drooling, especially in children.
Drooling indicates difficulty managing oral secretions and can be a sign of airway obstruction, necessitating immediate medical attention.
Choice B rationale:
Assessing for an earache is crucial because the infection from the tonsils can spread to the nearby ear structures, causing ear pain.
Earache in conjunction with other symptoms can indicate the spread of the infection and may require additional medical evaluation and treatment.
Choice C rationale:
Assessing for neck stiffness is important because it can be a sign of meningitis, a serious complication of some bacterial infections, including streptococcal bacteria that can cause tonsillitis.
Neck stiffness, along with other symptoms, can indicate the involvement of the central nervous system and requires urgent medical attention.
Choice D rationale:
Assessing for increased energy levels is not relevant to tonsillitis.
In fact, individuals with tonsillitis often experience fatigue due to the body's immune response to the infection.
Increased energy levels would not be a typical symptom of this condition.
Choice E rationale:
Assessing for vomiting is not a common symptom of tonsillitis.
While individuals with severe throat pain might have difficulty swallowing, leading to decreased oral intake, vomiting is not a direct symptom of tonsillitis.
Vomiting could indicate other underlying issues that need further assessment but is not specifically related to tonsillitis.
The child is experiencing severe throat pain and is refusing to drink fluids.
The nurse understands the importance of hydration in promoting recovery and preventing complications.
Which of the following statements should the nurse make to encourage the child to drink fluids?
Explanation
Choice A rationale:
This statement uses fear as a tactic to encourage the child to drink fluids, which is not a supportive or therapeutic approach.
It may create anxiety and resistance in the child, making them less likely to cooperate.
Choice B rationale:
This statement provides a positive and encouraging approach by explaining the benefits of drinking fluids.
It educates the child about the importance of hydration in feeling better faster, which can motivate them to cooperate with the nurse's recommendations.
Choice C rationale:
Threatening the child with an injection may create fear and distress, potentially worsening the child's refusal to drink fluids.
This approach is not conducive to building trust and cooperation with the child.
Choice D rationale:
Using threats related to discharge or privileges may cause stress and anxiety in the child.
It is important to maintain a supportive and reassuring approach to promote cooperation and comfort in the child.
The nurse is providing discharge education to the client and their family about the importance of completing the prescribed antibiotic therapy.
Which of the following statements should the nurse make?
Explanation
Choice A rationale:
Stopping antibiotics once feeling better can lead to incomplete eradication of the infection, allowing remaining bacteria to develop resistance to the antibiotic.
It is essential to complete the full course of antibiotics to ensure complete resolution of the infection.
Choice B rationale:
Finishing all the antibiotics, even if symptoms improve, is crucial to prevent the development of antibiotic-resistant strains of bacteria.
Incomplete courses of antibiotics can lead to treatment failure and potential complications.
Choice C rationale:
While it is important to monitor for and report any side effects of antibiotics, stopping the medication immediately without consulting a healthcare provider can compromise the effectiveness of the treatment.
The nurse should instruct the client to report any adverse reactions for proper evaluation and management.
Choice D rationale:
Sharing antibiotics with others is dangerous and highly discouraged.
Each person's condition is unique, and taking antibiotics without proper diagnosis and prescription can lead to inappropriate use, antibiotic resistance, and potential harm to individuals with allergies or other medical conditions.
Which of the following interventions should be included in the plan? (Select all that apply).
Explanation
Choice A rationale:
Encouraging the child to participate in strenuous physical activities is not appropriate for a child with tonsillitis.
Strenuous physical activities can exacerbate the symptoms and discomfort associated with tonsillitis.
Choice B rationale:
Providing pain relief measures, such as acetaminophen or ibuprofen, as prescribed, is essential in managing the pain and discomfort associated with tonsillitis.
These medications can help reduce pain and fever, improving the child's overall comfort.
Choice C rationale:
Offering cool or warm liquids and soft foods is crucial in soothing the throat and making it easier for the child to swallow.
Cold or warm liquids can help alleviate the discomfort, and soft foods are less likely to irritate the inflamed tonsils.
Choice D rationale:
Educating the child and family about the importance of completing prescribed antibiotic therapy is essential.
Tonsillitis caused by bacteria requires antibiotic treatment to eliminate the infection fully.
Incomplete antibiotic therapy can lead to treatment failure and recurrent infections.
Choice E rationale:
Discouraging rest and promoting active play is not appropriate for a child with tonsillitis.
Rest is essential for the body to heal, and promoting active play can worsen the symptoms and delay the healing process.
The nurse understands that this surgical intervention is considered for which of the following reasons?
Explanation
Choice A rationale:
Having at least one episode of tonsillitis might not be a sufficient indication for a tonsillectomy.
Tonsillectomy is typically considered for recurrent tonsillitis, not just a single episode.
Choice B rationale:
Tonsillectomy is considered when the child's tonsillitis does not respond to antibiotic therapy and becomes recurrent.
Recurrent tonsillitis can significantly impact a child's quality of life and may necessitate surgical intervention to prevent frequent infections and complications.
Choice C rationale:
Mild throat discomfort alone is not a strong indication for tonsillectomy.
Tonsillectomy is usually reserved for cases of recurrent tonsillitis that do not respond to conservative treatments.
Choice D rationale:
The parents' anxiety about their child's condition is not a direct indication for tonsillectomy.
The decision for surgery should be based on the child's medical condition and the medical necessity of the procedure.
The nurse knows that this medication is used for which of the following reasons?
Explanation
Choice A rationale:
Erythromycin is an antibiotic that does not primarily target inflammation and swelling in the tonsils.
Its mechanism of action involves inhibiting protein synthesis in bacteria, thereby preventing the growth and spread of the bacterial infection causing tonsillitis.
Choice B rationale:
Erythromycin is used to treat bacterial infections by inhibiting protein synthesis in bacteria.
It is effective against a wide range of bacterial strains and can be prescribed for various infections, including tonsillitis, caused by susceptible bacteria.
Choice C rationale:
Erythromycin does not provide symptomatic relief from throat pain and discomfort directly.
While it addresses the underlying bacterial infection, it does not have analgesic properties to relieve pain.
Pain relief measures, such as acetaminophen or ibuprofen, are typically prescribed for managing throat pain associated with tonsillitis.
Choice D rationale:
Erythromycin does not prevent dehydration by encouraging fluid intake.
While staying hydrated is essential during illness, the role of erythromycin is to target the bacterial infection, not to promote fluid intake.
RSV in children
The nurse wants to emphasize the importance of prevention, especially in the winter and early spring months.
Which of the following statements would be most effective for the nurse to use?
Explanation
Choice A rationale:
This statement is incorrect.
RSV is most common in winter and early spring, not summer and fall.
Stating this misinformation would not effectively educate the parents about RSV prevention during the high-risk months.
Choice B rationale:
This is The correct answer.
RSV does occur in yearly outbreaks, especially in winter and early spring.
By emphasizing this, the nurse educates parents about the specific periods when they should take extra precautions to prevent RSV transmission.
Choice C rationale:
This statement is incorrect.
RSV is indeed seasonal, with higher incidence during the winter and early spring months.
Denying its seasonality would provide inaccurate information to the parents.
Choice D rationale:
This statement is incorrect.
RSV primarily affects infants and young children, not adults.
Providing this misinformation would not help parents understand the risks associated with RSV for their children.
The client is particularly concerned about how long the virus can survive on surfaces.
Which of the following responses from the nurse would be most accurate?
Explanation
Choice A rationale:
This is The correct answer.
RSV can survive on hard surfaces for several days and on hands for several hours.
Providing this information addresses the client's concern about the virus's survivability on surfaces.
Choice B rationale:
This statement is incorrect.
RSV can survive on hard surfaces for a longer duration than just several hours.
Providing this incorrect information could lead to misunderstandings about RSV transmission.
Choice C rationale:
This statement is incorrect.
RSV can survive on surfaces, so stating that it cannot survive outside of the body would be inaccurate and misleading.
Choice D rationale:
This statement is incorrect.
RSV can be transmitted not only through direct contact with an infected person but also through contact with contaminated surfaces and respiratory droplets.
Which of the following findings should alert the nurse that the child may have RSV? (Select all that apply).
Explanation
Choice A rationale:
This statement is incorrect.
A history of recurrent pneumonia is not a specific indicator of RSV infection.
RSV primarily affects the respiratory system, causing symptoms such as cough, wheezing, and difficulty breathing.
Choice B rationale:
This is a correct answer.
RSV symptoms typically appear 2 to 5 days after exposure.
Including this option helps identify the duration of symptoms, which is relevant to diagnosing RSV.
Choice C rationale:
This is a correct answer.
RSV commonly presents with symptoms like high fever and severe cough.
Recognizing these symptoms can help healthcare providers consider RSV as a possible diagnosis.
Choice D rationale:
This is a correct answer.
RSV can lead to bronchiolitis, which is inflammation of the small airways in the lungs.
Diagnosing a child with bronchiolitis can raise suspicion of RSV infection.
Choice E rationale:
This statement is incorrect.
A history of bacterial infections is not specific to RSV and does not provide relevant information for identifying RSV infection in this context.
The client is concerned about the risk of transmission to their young grandchildren.
Which of the following statements should the nurse make?
Explanation
Choice A rationale:
RSV (Respiratory Syncytial Virus) primarily affects young children and infants, making them more vulnerable to severe complications.
Adults can also contract the virus, but it is most common and dangerous in children under one year old.
Therefore, stating that RSV is most common in adults is incorrect.
Choice B rationale:
RSV is most common in children under one year old, so your grandchildren could be at risk.
This statement is correct.
RSV is highly contagious and spreads through respiratory droplets.
Infants and young children are more prone to severe infections due to their underdeveloped immune systems.
Hence, the nurse should educate the client that their grandchildren, especially those under one year old, are at risk of contracting RSV.
Choice C rationale:
RSV does affect individuals with compromised immune systems, but it is not limited to them.
Children, especially those under one year old, are also highly susceptible to RSV infections.
Therefore, this statement is not comprehensive and accurate.
Choice D rationale:
RSV can be transmitted from person to person through respiratory secretions.
It is highly contagious, especially in crowded places like daycare centers and hospitals.
This statement is incorrect, as RSV transmission is well-documented.
Which of the following explanations should the nurse provide?
Explanation
Choice A rationale:
RSV infects the squamous epithelial cells of your bronchioles, alveoli, and nasal passages.
This statement is accurate.
RSV primarily targets the respiratory tract, infecting the cells lining the bronchioles, alveoli, and nasal passages.
This infection can lead to symptoms ranging from mild cold-like symptoms to severe respiratory distress, particularly in young children and individuals with weakened immune systems.
Choice B rationale:
RSV does not cause the immune system to attack the body's own cells.
It primarily targets the respiratory system, leading to respiratory symptoms.
Autoimmune responses are not associated with RSV infections.
Choice C rationale:
RSV does not lead to an overproduction of red blood cells.
This statement is incorrect and not related to the pathophysiology of RSV infections.
Choice D rationale:
RSV does not cause the body to stop producing white blood cells.
White blood cells play a crucial role in the immune response, and stopping their production would severely compromise the body's ability to fight infections.
RSV primarily affects the respiratory system and does not directly impact white blood cell production.
The child’s mother reports that the child has had a runny nose, fever, and decreased appetite for the past two days.
The nurse notes that the child appears irritable and has a persistent cough.
Based on these symptoms, the nurse suspects that the child’s illness may progress to bronchiolitis or pneumonia, which could cause more severe respiratory distress.
What statement should the nurse make to educate the mother about the potential progression of RSV infection?
Explanation
Choice A rationale:
Your child may start to experience difficulty breathing.
This statement is accurate and crucial for the mother to be aware of.
RSV infections can progress to bronchiolitis or pneumonia, leading to more severe respiratory distress.
Difficulty breathing is a common symptom in these advanced stages of the infection, indicating the need for immediate medical attention.
Choice B rationale:
While a decreased appetite is a symptom mentioned in the scenario, it does not reflect the potential progression of RSV infection.
The focus should be on respiratory symptoms, which can indicate worsening conditions.
Choice C rationale:
Drowsiness is not a typical symptom of RSV progression.
Respiratory distress, such as difficulty breathing, is a more concerning sign and requires prompt medical evaluation.
Choice D rationale:
Developing a high fever is a general symptom of various infections, including RSV.
While fever is a concern, the scenario specifically mentions symptoms related to the respiratory system, making difficulty breathing a more relevant and specific warning sign for the mother to be aware of.
The client is worried about the child’s persistent cough and decreased appetite.
The nurse explains that in children younger than age 3, RSV infection can progress to bronchiolitis or pneumonia, causing more severe respiratory distress.
What statement should the nurse make to reassure the client about the management of these potential complications?
Explanation
Choice A rationale:
The nurse should reassure the client by stating, “We will monitor your child closely for any signs of respiratory distress.”.
This is the appropriate response because close monitoring is crucial in children with RSV infection, especially those younger than age 3.
Respiratory distress can rapidly progress in this age group, and early detection is essential for timely intervention.
Monitoring the child's respiratory rate, oxygen saturation, and other respiratory symptoms allows healthcare providers to assess the severity of the condition and provide appropriate interventions promptly.
Choice B rationale:
While ensuring rest and fluids is generally good advice for managing various illnesses, it does not specifically address the client’s concerns about the potential complications of RSV infection, such as bronchiolitis or pneumonia leading to respiratory distress.
Choice C rationale:
Administering medication to reduce fever is not the most pertinent information in this scenario.
The primary concern for the client is the progression of RSV infection to severe respiratory distress, not fever reduction.
Choice D rationale:
Providing a special diet to improve appetite does not address the client’s concerns about the respiratory complications associated with RSV infection.
Respiratory distress is the main worry in this situation, and dietary changes are not the appropriate focus.
The nurse notes that the child’s respiratory rate is 35 breaths per minute, oxygen saturation is 96%, pH is 7.38, and PaCO2 is 40.
Which of the following actions should the nurse take based on these results? (Select all that apply).
Explanation
Choice A rationale:
Continuing to monitor the child’s respiratory rate is essential.
The nurse should closely observe the child's respiratory status to detect any changes.
Monitoring helps in assessing the effectiveness of interventions and identifying any worsening of the condition promptly.
Choice B rationale:
Administering supplemental oxygen is appropriate in this situation because the child's oxygen saturation is 96%, which indicates that the child is not receiving adequate oxygen.
Supplemental oxygen helps maintain appropriate oxygen levels and prevents hypoxia.
Choice C rationale:
Reassessing the child’s oxygen saturation in one hour is a good nursing practice to ensure that the child's respiratory status remains stable or improves.
Regular reassessment allows for timely adjustments in the treatment plan if needed.
Choice D rationale:
While the pH value is within the normal range (7.35-7.45), it is essential to consider the entire clinical picture.
The nurse should continue to monitor the child's respiratory status and other parameters.
Notification to the healthcare provider may be necessary if there are significant changes in the child's condition, but the pH value alone does not warrant immediate notification.
Choice E rationale:
Immediate intubation based solely on the elevated PaCO2 is not indicated.
The child's PaCO2 of 40 mmHg falls within the normal range (35-45 mmHg) for a 3-year-old.
Intubation is a significant intervention and should be considered based on the overall clinical assessment, including the child's respiratory distress, oxygen saturation, and other vital signs.
The toddler’s symptoms include wheezing, retractions, nasal flaring, tachypnea, and cyanosis.
The nurse understands that these symptoms indicate severe respiratory distress, which is common in children younger than age 3 with RSV infection.
Which of the following interventions should be included in the toddler’s care plan?
Explanation
Choice A rationale:
Administering bronchodilators as prescribed is appropriate for managing severe respiratory distress and wheezing in children with RSV infection.
Bronchodilators help dilate the airways, making it easier for the child to breathe.
This intervention addresses one of the specific symptoms mentioned in the scenario.
Choice B rationale:
Encouraging fluid intake is important to prevent dehydration, especially in children with respiratory infections.
It helps maintain hydration status, which is essential for overall health.
While important, this choice alone does not address the severe respiratory distress symptoms mentioned in the scenario.
Choice C rationale:
Monitoring oxygen saturation levels is crucial in children with RSV infection, especially when they exhibit symptoms of severe respiratory distress such as wheezing, retractions, nasal flaring, tachypnea, and cyanosis.
Monitoring oxygen saturation helps assess the child's oxygenation status and guides interventions such as oxygen therapy.
Choice D rationale:
The correct answer is choice D, “All of these.”.
This is because all the interventions mentioned in choices A, B, and C are appropriate and necessary for managing severe respiratory distress in a toddler with RSV infection.
Administering bronchodilators addresses airway constriction and wheezing, encouraging fluid intake prevents dehydration, and monitoring oxygen saturation levels ensures appropriate oxygenation, allowing comprehensive care for the child’s condition.
The nurse explains to the client that these symptoms are likely due to bronchiolitis or pneumonia, which are common complications of RSV infection in children younger than age 3.
Which of the following statements by the client indicates an understanding of the infant’s condition?
Explanation
Choice A rationale:
The nurse should educate the client about the expected course of RSV infection in infants.
RSV (Respiratory Syncytial Virus) infection can lead to complications such as bronchiolitis or pneumonia, especially in children under the age of 3.
Symptoms like wheezing and tachypnea are indicative of respiratory distress.
Educating the client about the expected duration of the symptoms is crucial.
The client needs to understand that the baby's symptoms may last for about 10 days, and this is a common timeframe for the resolution of RSV infection in infants.
This information helps manage the client's expectations and reduces anxiety.
Choice B rationale:
While fever can be a sign of infection, it is not the most pertinent symptom to monitor in this case.
The primary concern is the respiratory distress caused by bronchiolitis or pneumonia.
While fever might indicate worsening infection, it is not the most relevant information in this context.
Choice C rationale:
Over-the-counter cold medicine is generally not recommended for infants and young children due to the risk of side effects.
Moreover, these medications may not be effective in managing the specific symptoms caused by RSV infection.
Advising the client to administer such medication could be harmful and is not an appropriate response.
Choice D rationale:
While it is essential to prevent the spread of RSV infection, especially among siblings, this choice does not address the client's understanding of the infant's condition.
The primary concern here is the client's grasp of the infant's symptoms and the expected course of the illness, which is best addressed by choice A.
The nurse knows that maintaining a patent airway is crucial in the management of this condition.
The child’s mother asks the nurse, “What can I do to help my child breathe better?” Which of the following responses by the nurse would be most appropriate?
Explanation
Choice A rationale:
Keeping the child calm and comfortable is generally advisable, but in the context of RSV infection, maintaining a patent airway is crucial.
While comfort measures are essential, this choice does not directly address the mother's query regarding improving the child's breathing.
Choice B rationale:
This is The correct answer because suctioning the child's nose and mouth as needed helps in removing secretions, thus maintaining a clear airway.
RSV infection often leads to increased mucus production, which can obstruct the airways, making it difficult for the child to breathe.
By suctioning secretions, the mother can help her child breathe more comfortably, which is essential in managing RSV infection.
Choice C rationale:
Over-the-counter cold medicine is generally not recommended for infants and young children due to the risk of adverse effects.
Additionally, these medications may not specifically address the underlying cause of respiratory distress in RSV infection.
Choice D rationale:
Avoiding feeding the child until their breathing improves is not appropriate advice.
Nutrition is essential, especially for infants, and withholding feeding could lead to dehydration and other complications.
It is important to maintain adequate nutrition while managing the respiratory distress caused by RSV infection.
The client is concerned about the risk of dehydration for their child.
The nurse reassures the client by saying which of the following?
Explanation
Choice A rationale:
This is The correct answer because it addresses the client's concern about dehydration.
Infants and young children with RSV infection are at risk of dehydration due to increased respiratory effort, fever, and decreased oral intake.
Encouraging oral fluids or providing intravenous fluids as prescribed helps prevent dehydration, ensuring the child remains hydrated during the illness.
Choice B rationale:
While adequate fluid intake is essential, stating a specific quantity like 8 glasses of water a day is not appropriate for infants and young children.
The fluid requirements vary based on the child's age, weight, and overall health condition.
Providing a specific quantity without proper assessment can be misleading and may not meet the child's individual needs.
Choice C rationale:
Limiting the child's fluid intake to prevent overhydration is not the primary concern in this context.
Dehydration due to increased respiratory effort and decreased oral intake is a more significant concern.
Adequate hydration is crucial in preventing complications associated with dehydration.
Choice D rationale:
Restricting the child to clear liquids only is not appropriate, especially in the context of RSV infection.
While clear liquids are essential, they may not provide adequate nutrition.
Maintaining appropriate oral intake, which includes a variety of fluids and, if possible, nutritionally balanced foods, is important for the child's overall well-being during the illness.
Which of the following instructions should the nurse include? (Select all that apply).
Explanation
Choice A rationale:
Isolating the child from other children or adults with respiratory infections is crucial in preventing the spread of Respiratory Syncytial Virus (RSV).
RSV is highly contagious and spreads through respiratory droplets.
By isolating the infected child, the nurse helps prevent the transmission of the virus to others.
Choice B rationale:
Using contact precautions such as gown and gloves when caring for the child is essential to prevent the spread of RSV.
Direct contact with respiratory secretions can easily lead to transmission.
Wearing protective gear like gowns and gloves creates a barrier, reducing the risk of contamination and spread.
Choice C rationale:
Encouraging frequent hand hygiene is a fundamental preventive measure.
RSV can survive on surfaces for several hours, so regular handwashing with soap and water for at least 20 seconds can help eliminate the virus from hands, reducing the risk of infection.
Choice E rationale:
Avoiding exposure to tobacco smoke is important because smoke irritates the respiratory tract, making individuals more susceptible to respiratory infections like RSV.
Secondhand smoke can also worsen symptoms in infected individuals and increase the severity of the illness.
Choice D rationale:
Allowing siblings to share toys and utensils with the infected child is not recommended.
RSV spreads through respiratory droplets and direct contact with contaminated surfaces.
Sharing toys and utensils can facilitate the transmission of the virus to other children, increasing the risk of infection.
Which of the following statements by the client indicates an understanding of the teaching?
Explanation
Choice B rationale:
Offering frequent small feedings of breast milk or formula to maintain nutrition is an appropriate response.
Infants with RSV may experience decreased appetite and difficulty feeding due to respiratory distress.
Providing small, frequent feedings ensures that the infant receives adequate nutrition and hydration despite reduced intake during each feeding session.
Choice A rationale:
Giving the baby aspirin if they develop a fever is not recommended.
Aspirin use in children with viral infections like RSV has been associated with Reye's syndrome, a severe and potentially fatal condition.
Acetaminophen or ibuprofen, if appropriate for the child's age, can be used to manage fever and discomfort.
Choice C rationale:
Keeping the baby in a flat position to promote comfort is not advisable.
Elevating the head of the crib or bassinet slightly can help improve breathing and reduce nasal congestion in infants with respiratory infections, promoting better comfort and easier breathing.
Choice D rationale:
Stopping all feedings if the baby seems to be having trouble breathing is not The correct approach.
Adequate nutrition is crucial for the infant's overall health and recovery.
Instead, the caregiver should seek medical advice if the baby experiences significant difficulty breathing or feeding.
Adjustments in feeding techniques or temporary alternative feeding methods may be recommended under medical supervision.
Epiglottitis
The child presents with a muffled voice and is leaning forward with outstretched arms.
Which statement regarding epiglottitis is accurate?
Explanation
Choice A rationale:
Epiglottitis is most commonly caused by bacterial infections, specifically Haemophilus influenzae type b (Hib) bacteria.
This bacterium can cause inflammation and swelling of the epiglottis, leading to airway obstruction.
Viral infections are not the primary cause of epiglottitis in children.
Choice B rationale:
Epiglottitis primarily affects children, not adolescents and adults.
The peak incidence occurs in children between the ages of 2 and 6 years.
Choice C rationale:
The child adopting a tripod position, leaning forward with outstretched arms, is a classic sign of epiglottitis.
This position helps maximize airway patency and ease breathing.
It is a protective mechanism that children instinctively assume to maintain their airway.
Choice D rationale:
Epiglottitis does not typically result in a loud, high-pitched cry.
The child with epiglottitis is usually quiet and prefers to sit still in a tripod position to maintain airway patency.
The client is drooling saliva and has difficulty swallowing.
Which statement accurately describes the pathophysiology of epiglottitis?
Explanation
Choice A rationale:
Epiglottitis does not cause the epiglottis to shrink and recede into the throat.
Instead, it leads to inflammation and swelling of the epiglottis, causing airway obstruction.
Choice B rationale:
The inflammation in epiglottitis does not primarily affect the vocal cords.
It specifically affects the epiglottis, a flap-like structure located at the base of the tongue, which covers the trachea during swallowing to prevent food or liquid from entering the windpipe.
Choice C rationale:
Epiglottitis leads to increased airway resistance and respiratory distress due to the swelling and obstruction of the airway.
This can result in difficulty swallowing, drooling, and a muffled voice, as seen in the client's symptoms described in the question.
Choice D rationale:
The swelling in epiglottitis is not limited to the vocal cord area.
It involves the epiglottis, which can obstruct the airway and cause respiratory distress.
Which factors should the nurse include in the discussion?
Explanation
Choice A rationale:
Haemophilus influenzae type b (Hib) infection is a significant risk factor for epiglottitis in children.
Hib vaccination has significantly reduced the incidence of epiglottitis caused by this bacterium.
Choice B rationale:
Trauma to the throat or neck is not a common risk factor for epiglottitis.
The primary cause is bacterial infection, especially by Hib bacteria.
Choice C rationale:
Thermal injury from hot liquids can lead to thermal epiglottitis, a rare condition caused by the inhalation of hot steam or liquid, resulting in inflammation and swelling of the epiglottis.
Choice D rationale:
Seasonal factors are not a direct risk factor for epiglottitis.
The condition is primarily caused by bacterial infections and is not significantly influenced by seasonal changes.
Choice E rationale:
Mycoplasma pneumoniae infection is not a common cause of epiglottitis.
Bacterial infections, especially Hib, are the primary culprits in pediatric cases of epiglottitis.
The child is leaning forward and has a muffled voice.
Which statement is true regarding the demographics of epiglottitis?
Explanation
Choice A rationale:
Epiglottitis is not necessarily more common in females than in males.
It can affect both genders equally.
Choice B rationale:
While epiglottitis is more common in children, it primarily affects those between the ages of 2 and 8 years old, not just infants under 1 year old.
Choice C rationale:
There is no significant evidence to suggest that epiglottitis is more prevalent in colder months.
The occurrence of epiglottitis is not strictly related to seasonal changes.
Choice D rationale:
Children between 2 and 8 years old are at higher risk of developing epiglottitis.
This age group is more susceptible due to their smaller airways and less developed immune systems, making them prone to infections like epiglottitis.
What is the most common causative agent of epiglottitis in children?
Explanation
Choice A rationale:
Streptococcus pneumoniae is a common bacterium associated with respiratory infections, but it is not the most common causative agent of epiglottitis in children.
Choice B rationale:
Staphylococcus aureus can cause various infections, but it is not the primary causative agent of epiglottitis in children.
Choice C rationale:
Haemophilus influenzae type b (Hib) is the most common causative agent of epiglottitis in children.
Hib infection can lead to inflammation and swelling of the epiglottis, causing the characteristic symptoms of epiglottitis, including difficulty swallowing and a muffled voice.
Choice D rationale:
Neisseria meningitidis is a bacterium that can cause meningitis and septicemia, but it is not the main causative agent of epiglottitis.
Which clinical manifestation should the nurse prioritize when evaluating the severity of the condition?
Explanation
Choice A rationale:
Difficulty swallowing and throat pain are common symptoms of epiglottitis, but they do not necessarily indicate the severity of the condition.
Choice B rationale:
Feeling anxious and restless may be a sign of distress, but it does not specifically indicate the severity of epiglottitis.
Choice C rationale:
Making a high-pitched sound when breathing (called stridor) is a serious symptom indicating airway obstruction.
While this is concerning, it is not the most critical manifestation in evaluating the severity of epiglottitis.
Choice D rationale:
Cyanosis, characterized by a bluish discoloration of the skin and lips, indicates severe lack of oxygen and is a critical sign in assessing the severity of epiglottitis.
Cyanosis suggests inadequate oxygenation and is indicative of impending respiratory failure, requiring immediate medical intervention.
Which statement made by the child would be most concerning for the nurse?
Explanation
Choice A rationale:
The statement "My throat is really sore.”.
is a common symptom of throat infections, including epiglottitis.
While it is concerning, it is not the most concerning symptom in this case.
Epiglottitis can rapidly progress, leading to respiratory distress, which is a life-threatening condition.
Choice B rationale:
The statement "I can't stop drooling.”.
is a significant concern in a child suspected of having epiglottitis.
Drooling and difficulty managing secretions are hallmark signs of epiglottitis and indicate compromised airway protection.
This symptom suggests that the epiglottis is inflamed and obstructing the airway, potentially leading to respiratory distress and the need for urgent intervention.
Choice C rationale:
The statement "I feel restless and agitated.”.
is a non-specific symptom and may be seen in various illnesses, including infections.
While it indicates the child's discomfort, it does not directly point to the severity of the condition or airway compromise, making it less concerning than the inability to handle secretions.
Choice D rationale:
The statement "I'm having trouble breathing.”.
is the most concerning symptom in a child suspected of having epiglottitis.
Difficulty breathing indicates significant airway obstruction, which can rapidly progress to respiratory failure.
This symptom requires immediate medical attention and intervention to secure the airway and prevent further complications.
Select all the clinical manifestations that are characteristic of epiglottitis.
Explanation
Choice A rationale:
Drooling and inability to handle secretions are characteristic manifestations of epiglottitis.
Inflamed epiglottis impairs the child's ability to swallow and manage saliva, leading to drooling.
This symptom is a key clinical indicator of epiglottitis.
Choice B rationale:
Cough and wheezing are not typical manifestations of epiglottitis.
Epiglottitis primarily affects the upper airway, leading to symptoms such as drooling, stridor, and respiratory distress.
Cough and wheezing are more common in lower respiratory tract infections, such as bronchitis or pneumonia.
Choice C rationale:
Cyanosis and pallor are not specific to epiglottitis and can occur in various respiratory and cardiovascular conditions.
While these symptoms indicate decreased oxygenation, they are not unique to epiglottitis and are not considered characteristic manifestations of this condition.
Choice D rationale:
Muffled voice and stridor are characteristic signs of epiglottitis.
A muffled voice occurs due to the swollen epiglottis obstructing airflow, resulting in a change in the sound of the child's voice.
Stridor is a high-pitched, noisy breathing sound that occurs during inspiration and indicates partial airway obstruction.
Both symptoms are indicative of compromised upper airway in epiglottitis.
Choice E rationale:
Tachypnea (rapid breathing) and tachycardia (rapid heartbeat) are common physiological responses to respiratory distress.
In epiglottitis, the child may exhibit these symptoms due to the body's attempt to compensate for decreased oxygen levels.
These manifestations reflect the severity of the condition and the child's physiological response to airway compromise.
Explanation
Choice A rationale:
Computed tomography (CT) scan provides detailed images of internal structures but is not the preferred imaging test for visualizing a swollen epiglottis.
CT scans are more commonly used for evaluating conditions in other parts of the body, such as the brain or abdomen, and may not provide the necessary detail for assessing the upper airway.
Choice B rationale:
Magnetic resonance imaging (MRI) can produce high-resolution images of soft tissues, but it is not the first choice for visualizing a swollen epiglottis.
MRI scans are time-consuming and may not be readily available in urgent situations.
In cases of suspected epiglottitis, prompt diagnosis and intervention are crucial to prevent respiratory compromise.
Choice C rationale:
Lateral neck radiograph is the preferred imaging test for visualizing a swollen epiglottis.
This X-ray technique allows healthcare providers to assess the size of the epiglottis and its relationship with nearby structures.
A classic finding in epiglottitis on a lateral neck radiograph is a swollen epiglottis, giving a thumbprint sign appearance.
This imaging study can aid in the diagnosis and guide appropriate management.
Choice D rationale:
X-ray of the chest is not the preferred imaging test for evaluating epiglottitis.
While a chest X-ray can provide information about the lungs and surrounding structures, it does not offer the necessary detail to visualize the upper airway, including the epiglottis.
Lateral neck radiograph is specifically tailored to assess the structures in the throat region and is the imaging modality of choice in suspected cases of epiglottitis.
Explanation
Choice A rationale:
Allergies to foods are not directly related to epiglottitis.
While it's essential information for a general health assessment, it doesn't provide specific insights into the condition.
Choice B rationale:
Immunization history is crucial in the assessment of a child with suspected epiglottitis.
Haemophilus influenzae type b (Hib) vaccination is highly effective in preventing epiglottitis caused by Hib bacteria.
Knowing the child's immunization status helps the nurse assess the likelihood of Hib infection.
Choice C rationale:
Recent travel destinations are not directly relevant to epiglottitis.
This information is more pertinent when assessing the risk of diseases like malaria or dengue fever, which are region-specific.
Choice D rationale:
Current hobbies and interests are not pertinent to the assessment of epiglottitis.
This information is important in a broader context for understanding the child's lifestyle but does not provide relevant data regarding the condition.
Which nursing intervention should the nurse prioritize to maintain a patent airway?
Explanation
Choice A rationale:
Administering antibiotics intravenously is important in treating the infection, but it doesn't directly address maintaining a patent airway.
The priority in epiglottitis is to ensure an open airway to prevent respiratory distress.
Choice B rationale:
Providing humidified air or cool mist therapy helps moisten the airway, making it easier for the child to breathe.
This intervention can provide immediate relief and aid in maintaining a patent airway, which is crucial in epiglottitis.
Choice C rationale:
Administering corticosteroids intravenously can help reduce inflammation, but it might not be the primary intervention to maintain a patent airway.
Humidified air therapy directly addresses airway moisture, which is essential in epiglottitis management.
Choice D rationale:
Administering analgesics and antipyretics can address pain and fever associated with epiglottitis but does not directly contribute to maintaining a patent airway.
While these medications can improve the child's comfort, they are not the priority in this situation.
What information should the nurse include in the education?
Explanation
Choice A rationale:
The importance of oral medications to relieve symptoms is relevant, but it doesn't specifically prevent epiglottitis.
Preventive measures like vaccination are more crucial in avoiding the condition.
Choice B rationale:
Educating the child and their family about the signs and symptoms of epiglottitis is essential for early recognition and prompt medical intervention.
Understanding the symptoms can lead to quicker medical attention, which is vital in managing epiglottitis effectively.
Choice C rationale:
Avoiding complete immunization against Hib is not a recommended practice.
Hib vaccination significantly reduces the risk of epiglottitis caused by Hib bacteria.
Encouraging complete immunization is a key preventive measure against the disease.
Choice D rationale:
Using nebulized medications for treatment might be a part of the management plan if the child already has epiglottitis, but it's not a preventive measure.
Prevention focuses on vaccination and awareness of symptoms, making choice D less relevant in the context of prevention.
Select all appropriate interventions for supportive care.
Explanation
Choice A rationale:
Administering antibiotics intravenously as prescribed is a crucial intervention in the management of epiglottitis.
Epiglottitis is commonly caused by bacterial infections, and intravenous antibiotics are essential to target the underlying infection and prevent its spread.
The choice of antibiotic should be based on the specific causative organism and local antibiotic resistance patterns.
Choice B rationale:
Administering corticosteroids intravenously as prescribed is another important intervention in the supportive care of epiglottitis.
Corticosteroids help reduce airway inflammation, which is a significant concern in epiglottitis.
By decreasing inflammation, corticosteroids can alleviate respiratory distress and improve the patient's breathing.
Choice C rationale:
Providing hydration and nutrition by intravenous fluids is necessary in the management of epiglottitis, especially if the child is having difficulty swallowing or breathing.
Intravenous fluids ensure that the child receives adequate hydration and nutrition while minimizing the risk of aspiration, which can worsen the airway obstruction.
Choice E rationale:
Providing humidified air or cool mist therapy to moisten the airway is a supportive measure that can help ease breathing difficulties in children with epiglottitis.
Humidified air or cool mist therapy can soothe the inflamed airway, making it easier for the child to breathe.
It is essential to maintain a moist environment to prevent further irritation and discomfort.
Choice D rationale:
Educating the child and family about the prevention of epiglottitis is important for overall health awareness, but it is not a direct supportive intervention for a child already diagnosed with the condition.
While prevention strategies, such as timely vaccinations and good hygiene, are crucial, they do not constitute immediate supportive care for a child with active epiglottitis.
Which statement about airway management is correct?
Explanation
Choice A rationale:
Tracheostomy may be necessary in severe cases of epiglottitis where the airway obstruction is life-threatening and cannot be managed with other interventions.
In such cases, creating a surgical airway via tracheostomy can provide a more stable and secure airway, ensuring adequate oxygenation.
However, this option is typically considered when other measures, such as intubation, have failed or are not feasible due to the severity of the obstruction.
Choice B rationale:
Intubation may be required in cases where the airway obstruction is significant, and the child is unable to maintain oxygenation and ventilation adequately.
Intubation allows for mechanical ventilation, ensuring a patent airway and adequate oxygen supply.
However, it is not always the only option and may depend on the severity of the condition and the response to other interventions.
Choice C rationale:
Tracheostomy is more invasive than intubation.
While tracheostomy is a surgical procedure that involves creating an opening in the trachea, intubation involves inserting a tube through the mouth or nose into the trachea.
Tracheostomy is considered more invasive because it requires a surgical incision and the placement of a permanent or temporary tracheostomy tube.
Choice D rationale:
Intubation is not always the first choice for airway management in epiglottitis.
The choice of airway management (intubation, tracheostomy, or other interventions) depends on the severity of the airway obstruction, the child's clinical condition, and the healthcare provider's assessment.
Intubation may be chosen if the obstruction is significant and the child cannot maintain adequate oxygenation and ventilation.
What should the nurse monitor for as potential side effects of corticosteroid therapy?
Explanation
Choice A rationale:
The nurse should monitor for signs of adrenal insufficiency and hyperglycemia as potential side effects of corticosteroid therapy.
Corticosteroids can suppress the adrenal glands, leading to adrenal insufficiency, which can manifest as weakness, fatigue, low blood pressure, and abdominal pain.
Hyperglycemia (elevated blood sugar levels) is a common side effect of corticosteroids and can worsen diabetes or predispose non-diabetic individuals to high blood sugar levels.
Choice B rationale:
Decreased oxygen saturation levels are not a common side effect of corticosteroid therapy.
Corticosteroids help reduce airway inflammation, which can actually improve oxygenation in conditions like epiglottitis by reducing airway obstruction and respiratory distress.
Choice C rationale:
Allergic reactions to corticosteroids are possible, but they are relatively rare.
Symptoms of an allergic reaction can include rash, itching, swelling, severe dizziness, or difficulty breathing.
While allergic reactions are a concern with any medication, they are not the primary side effect that nurses should monitor for when administering corticosteroids.
Choice D rationale:
Increased sensitivity to antibiotics is not a known side effect of corticosteroid therapy.
Corticosteroids work by suppressing the immune response and reducing inflammation, but they do not affect the body's sensitivity to antibiotics.
Antibiotic effectiveness is determined by factors such as the specific antibiotic used, the type of bacteria causing the infection, and antibiotic resistance patterns.
Otitis media
Which of the following statements accurately describes the primary cause of otitis media as per the information provided in the text?
Explanation
Choice A rationale:
Otitis media is not mainly caused by the presence of bacteria in the middle ear.
While bacterial infections can contribute to otitis media, it is not the primary cause as per the information provided in the text.
Choice B rationale:
Eustachian tube dysfunction is indeed the primary cause of otitis media.
The Eustachian tube connects the middle ear to the back of the throat.
When this tube is not functioning correctly, it can lead to the accumulation of fluid in the middle ear, providing an ideal environment for bacterial growth and infection, which results in otitis media.
Choice C rationale:
Otitis media is not primarily caused by allergic reactions.
While allergies can lead to Eustachian tube dysfunction, it is not the main cause of otitis media.
Choice D rationale:
The statement that "The risk factors for otitis media are not well-defined" is incorrect.
The risk factors for otitis media are well-established, including factors like age (more common in children), exposure to smoke, attending daycare, and Eustachian tube abnormalities.
Which statement accurately describes one of the risk factors mentioned in the text for developing otitis media?
Explanation
Choice A rationale:
Otitis media is more common in young children, especially those between 6 months and 3 years of age.
It is not more common in children over 6 years of age.
Choice B rationale:
Seasonal changes can indeed impact the frequency of otitis media.
During cold seasons, upper respiratory infections are more common, which can lead to otitis media.
Choice C rationale:
Noncompliance with vaccinations is associated with otitis media.
Proper vaccination can prevent certain infections that may lead to otitis media.
Choice D rationale:
Passive smoking can increase the risk of otitis media.
Exposure to secondhand smoke can cause irritation and inflammation in the Eustachian tubes, making individuals, especially children, more susceptible to ear infections.
Which of the following statements regarding the pathophysiology of otitis media, as described in the text, are correct? (Choose three.).
Explanation
Choice A rationale:
Eustachian tube obstruction does lead to decreased pressure in the middle ear.
When the Eustachian tube is blocked or not functioning properly, it can create a vacuum in the middle ear, leading to negative pressure, which can pull fluid into the middle ear space.
Choice B rationale:
Effusion is indeed the fluid that fills the normally air-filled middle ear cavity in otitis media.
This fluid can accumulate due to Eustachian tube dysfunction or inflammation, leading to the characteristic symptoms of otitis media.
Choice C rationale:
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are indeed common pathogens causing otitis media.
These bacteria can infect the middle ear and lead to the inflammation and fluid accumulation characteristic of otitis media.
Choice D rationale:
Otitis media does not result from the inflammation of the outer ear.
Otitis media specifically refers to inflammation and infection of the middle ear.
Choice E rationale:
The statement about the eardrum becoming red, swollen, and bulging due to the absence of effusion is incorrect.
The presence of effusion behind the eardrum can cause it to appear red, swollen, and bulging, not the absence of effusion.
Which of the following complications is mentioned in the text as a potential consequence of otitis media?
Explanation
Choice A rationale:
Migraines and tension headaches are not mentioned as complications of otitis media in the text.
Otitis media primarily affects the middle ear and is associated with complications related to the ear and hearing.
Choice B rationale:
Chronic back pain and joint issues are unrelated to otitis media.
The complications of otitis media are primarily associated with the ear, hearing, and speech.
Choice C rationale:
Speech delay and hearing loss are mentioned as potential consequences of otitis media.
Otitis media can lead to hearing impairment, especially in children, which can subsequently cause speech delays.
This complication occurs due to the accumulation of fluid in the middle ear, which impairs the normal conduction of sound.
Choice D rationale:
Skin rashes and allergic reactions are not mentioned as consequences of otitis media.
Complications of otitis media primarily revolve around the auditory system and related functions.
Which of the following factors mentioned in the text as risk factors for otitis media is most closely associated with an increased exposure to infectious agents?
Explanation
Choice A rationale:
Age alone is not a risk factor for otitis media.
However, certain age groups, such as young children, are more susceptible to ear infections due to their developing immune systems and shorter Eustachian tubes.
Choice B rationale:
Season is not a direct risk factor for otitis media.
While certain respiratory infections might be more common in specific seasons, otitis media itself is not strongly influenced by seasonal changes.
Choice C rationale:
Allergies can contribute to ear infections, but they are not the most closely associated risk factor mentioned in the context.
Allergies can lead to inflammation and fluid buildup in the middle ear, making individuals more prone to infections.
However, in the given options, day care attendance is a more specific risk factor related to exposure to infectious agents.
Choice D rationale:
Day care attendance is closely associated with an increased exposure to infectious agents, including the bacteria that can cause otitis media.
Children in day care settings are in close contact with others, facilitating the spread of infections.
Which clinical manifestations are commonly associated with AOM? Select The correct statements from the following options:.
Explanation
and "Balance problems result from serous fluid in the ear canal.”.
Choice A rationale:
The statement that "The ear pain is usually mild and intermittent" is incorrect.
Ear pain associated with acute otitis media (AOM) is often severe and continuous, causing discomfort and distress to the affected individual.
Choice B rationale:
Irritability, manifested as crying or fussiness, is a common symptom of AOM.
Ear pain and pressure can cause considerable discomfort, leading to irritability and changes in behavior, especially in children.
Choice C rationale:
The statement "Hearing loss in AOM is typically severe" is incorrect.
While hearing loss can occur in AOM, it is not always severe.
The degree of hearing impairment can vary based on the severity of the infection and the presence of fluid in the middle ear.
Choice D rationale:
Balance problems resulting from serous fluid in the ear canal are correct.
Serous fluid buildup in the middle ear can affect the balance mechanisms, leading to balance issues and dizziness, especially in children.
This fluid buildup can cause pressure changes, impacting the normal functioning of the inner ear.
Choice E rationale:
Otorrhea, which refers to discharge from the ear, is not a common symptom of AOM.
Otorrhea is more commonly associated with chronic ear infections or other ear conditions but not necessarily with acute otitis media.
Which symptoms should the nurse inquire about in the child's history to assess for otitis media? Choose the appropriate options from the following:.
Explanation
Choice A rationale:
A history of frequent episodes of otitis media is important to inquire about because recurrent ear infections are a common sign of otitis media.
Children who have experienced multiple episodes of otitis media are at a higher risk for developing the condition again.
This information helps the nurse assess the child's susceptibility to ear infections and guides further evaluation and treatment decisions.
Choice B rationale:
Previous upper respiratory tract infections are relevant to the child's overall health but are not specific symptoms of otitis media.
Otitis media can be a complication of upper respiratory infections, but the presence of previous infections alone does not confirm otitis media.
Choice C rationale:
Exposure to loud noise as a daily occurrence is not a symptom of otitis media.
Otitis media is an inflammation of the middle ear, commonly caused by bacterial or viral infections, and is not related to exposure to loud noises.
Choice D rationale:
A feeling of fullness or pressure in the ear can be associated with otitis media, but it is a nonspecific symptom that can occur in various ear conditions.
While it may raise suspicion, it is not a definitive sign of otitis media.
Choice E rationale:
Immunization history of the child is important for the child's overall health, but it is not a specific symptom of otitis media.
Immunizations do not directly influence the development or presence of otitis media.
Which findings indicate acute otitis media (AOM) based on the examination of the tympanic membrane? Select all that apply:.
Explanation
Choice A rationale:
Redness of the tympanic membrane can indicate inflammation, which is a common sign of acute otitis media (AOM).
Inflammation causes increased blood flow to the area, leading to redness and often pain.
Choice B rationale:
Bulging of the tympanic membrane occurs when there is increased pressure behind the eardrum, often due to fluid accumulation.
In the context of acute otitis media, this bulging is caused by the buildup of pus or other fluids in the middle ear.
Choice C rationale:
Purulence (pus) observed in the ear canal is a definitive sign of acute otitis media.
The presence of pus indicates an active infection within the middle ear.
Choice D rationale:
Orange discoloration of the tympanic membrane is not a typical finding in acute otitis media.
The color change could be due to various factors but is not specific to this condition.
Choice E rationale:
Decreased mobility of the tympanic membrane can occur due to the accumulation of fluid in the middle ear, leading to impaired movement.
This decreased mobility is often observed in acute otitis media and contributes to the diagnosis.
Which assessment findings are more likely associated with otitis media with effusion (OME)? Select The correct statements:.
Explanation
Choice A rationale:
The child reporting severe, throbbing ear pain is more indicative of acute otitis media (AOM) rather than otitis media with effusion (OME).
Severe pain is a common symptom of an active infection in the middle ear.
Choice B rationale:
Pus observed draining from the ear canal is a sign of acute otitis media (AOM).
Drainage indicates a ruptured eardrum, allowing the infected fluid to escape, relieving pressure and pain.
Choice C rationale:
Hearing loss that is mild to moderate is characteristic of otitis media with effusion (OME).
OME occurs when fluid remains trapped in the middle ear after the infection has resolved.
The presence of fluid can affect hearing, especially at lower frequencies, leading to mild to moderate hearing loss.
Choice D rationale:
The eardrum appearing red and bulging is a typical finding in acute otitis media (AOM), not otitis media with effusion (OME).
In AOM, the eardrum becomes red due to inflammation and bulges due to increased pressure from fluid buildup.
What clinical manifestations are indicative of hearing loss in children with otitis media? Choose the appropriate options:.
Explanation
"Difficulty locating sounds or following directions.”.
Choice A rationale:
Difficulty locating sounds or following directions is a common sign of hearing loss in children with otitis media.
Hearing loss can affect a child's ability to hear and process sounds, leading to problems in locating the source of sounds or following instructions.
This manifestation is indicative of conductive hearing loss, which is commonly associated with otitis media.
Children may have trouble understanding speech, especially in noisy environments.
Choice B rationale:
Ringing or buzzing sound in the ear, also known as tinnitus, is not a typical manifestation of hearing loss in otitis media.
Tinnitus can occur due to various reasons, but it is not a specific indicator of hearing loss associated with otitis media.
Choice C rationale:
Severe, pulsating ear pain is a symptom of acute otitis media, but it is not directly indicative of hearing loss.
Ear pain is caused by the buildup of fluid and pressure in the middle ear, leading to discomfort and pain.
However, it does not necessarily mean the child has hearing loss.
Choice D rationale:
Vertigo and nystagmus are symptoms associated with inner ear disorders, such as vestibular labyrinthitis or Meniere's disease, but they are not typical manifestations of hearing loss in otitis media.
These symptoms involve problems with balance and coordination and are not directly related to hearing loss.
Choice E rationale:
Inconsolable crying due to discomfort is a general symptom that can occur in children with various illnesses, including otitis media.
While it indicates the child is in pain or discomfort, it is not a specific sign of hearing loss.
Children may cry due to ear pain, but this symptom alone does not confirm hearing loss.
Which aspect should the nurse evaluate regarding pain?
Explanation
"The pain gets worse when I lie down.”.
Choice A rationale:
"I feel a sharp pain in my ear sometimes.”.
This statement suggests intermittent ear pain, which can occur in otitis media when there is a sudden change in pressure in the middle ear.
It is a possible symptom, but it is not specific to otitis media as other ear conditions can also cause sharp ear pain.
Choice B rationale:
"My ear hurts all the time.”.
Constant ear pain is a common symptom of acute otitis media.
The pain is caused by inflammation and pressure in the middle ear.
This symptom is indicative of otitis media but does not provide specific information about the pain worsening when lying down, which is a crucial aspect to assess.
Choice C rationale:
"The pain gets worse when I lie down.”.
This statement is indicative of otitis media.
When the child lies down, the fluid in the middle ear can put additional pressure on the eardrum, causing increased pain.
This worsening of pain in specific positions helps differentiate otitis media from other ear conditions.
Choice D rationale:
"I have no pain in my ear.”.
Absence of ear pain is not consistent with otitis media.
Otitis media is characterized by ear pain, especially in acute cases when there is inflammation and pressure in the middle ear.
Lack of ear pain suggests the absence of this condition.
Explanation
"I have a high fever, and I'm shivering.”.
Choice A rationale:
"I have a high fever, and I'm shivering.”.
A high fever with chills indicates a systemic response to infection, which can be seen in severe cases of otitis media.
Fever is a common symptom and can indicate a spreading or worsening infection.
Shivering (rigors) often accompanies a high fever and suggests a significant inflammatory response in the body.
Choice B rationale:
"I feel warm, but I'm not sweating.”.
Feeling warm without sweating may indicate a low-grade fever, which can occur in various infections, including otitis media.
However, this statement does not provide information about the severity of the fever or the child's overall condition.
Choice C rationale:
"I'm sweating a lot, and I'm very tired.”.
Sweating and fatigue can be symptoms of various illnesses, including infections.
Sweating, especially if accompanied by other symptoms like fever, can indicate a fever breaking, but it does not specifically provide information about the severity of the infection or its relationship to otitis media.
Choice D rationale:
"I don't have a fever at all.”.
The absence of fever is not consistent with acute otitis media.
Fever is a common systemic response to infection and inflammation.
In the context of otitis media, the presence of fever indicates a more severe or active infection.
Select all the appropriate assessment findings the nurse should consider.
Explanation
Choice A rationale:
The nurse should consider the results of the whisper test when assessing a child with otitis media.
A whisper test helps to assess hearing acuity and can indicate if there is a hearing impairment in the child.
If the child does not respond appropriately to the whisper test, it could suggest hearing problems related to otitis media.
Choice B rationale:
Assessing the child's response to sounds is crucial in evaluating their hearing abilities.
Children with otitis media may have difficulty hearing soft sounds or may not respond appropriately to auditory stimuli.
This assessment finding can provide valuable information about the child's hearing status and potential issues related to otitis media.
Choice D rationale:
Considering the child's history of hearing problems is essential in understanding the overall context of their ear health.
A history of recurrent ear infections or hearing difficulties can indicate a chronic issue, such as otitis media, which the nurse needs to address and monitor closely.
Past hearing problems can influence the current assessment and guide appropriate interventions.
Choice C rationale:
Temperature measurement is not directly related to assessing a child with otitis media.
Otitis media primarily affects the middle ear, leading to symptoms such as ear pain, hearing loss, and sometimes drainage from the ear.
Monitoring the child's temperature is important for assessing fever, which could be a sign of infection, but it is not specific to otitis media assessment.
Choice E rationale:
Lip reading skills are not typically assessed in the context of otitis media.
Otitis media primarily affects the auditory system, leading to hearing difficulties.
While lip reading skills might be relevant for individuals with profound hearing loss, it is not a standard assessment for children with otitis media, especially during a comprehensive assessment.
Explanation
Choice A rationale:
The statement "I sometimes feel dizzy and unsteady" indicates balance problems in the child.
Balance issues can occur in individuals with otitis media due to disturbances in the inner ear, affecting the vestibular system responsible for balance and spatial orientation.
Dizziness and unsteadiness are common symptoms associated with inner ear problems, including otitis media.
Therefore, this statement should be evaluated further to assess the child's balance and related concerns.
Choice B rationale:
The statement "My ear feels heavy" is related to a sensation in the ear and does not specifically indicate balance problems.
While otitis media can cause ear discomfort and pain, the sensation of heaviness alone does not provide information about the child's balance issues.
It is important to differentiate between symptoms related to ear discomfort and those indicating problems with balance.
Choice C rationale:
The statement "I have trouble swallowing" is not directly related to balance problems associated with otitis media.
Swallowing difficulties are typically not a primary symptom of otitis media.
This statement might indicate issues with the throat or esophagus but does not provide relevant information about the child's balance concerns.
Choice D rationale:
The statement "I can balance perfectly" suggests that the child does not experience balance problems.
This statement contradicts the typical symptoms associated with otitis media, which can include dizziness, unsteadiness, and balance issues.
If the child can balance perfectly, it indicates that their vestibular system, responsible for balance, is functioning normally and is not affected by otitis media.
Which of the following is NOT a way to manage otitis media in children?
Explanation
The correct answer is Choice B: Antivirals.
Choice A rationale:
Watchful waiting is a valid approach, especially for mild cases of otitis media, allowing time to see if the condition improves on its own.
Choice B rationale:
Antivirals are not typically used to manage otitis media because it is usually caused by bacterial infections or fluid buildup rather than viruses.
Choice C rationale:
Myringotomy, which involves creating a small incision in the eardrum to drain fluid, is an effective treatment for recurrent or severe cases of otitis media.
Choice D rationale:
Administration of over-the-counter pain relievers helps manage pain and discomfort associated with otitis media and is a common recommendation.
Gastroenteritis in Children:
The nurse asks the child's parent, "Have you noticed any changes in your child's bowel movements recently?" What would be an expected statement from the parent?
Explanation
Choice A rationale:
The parent's statement, "Yes, my child has had frequent diarrhea," is expected in a child with gastroenteritis caused by a viral infection.
Viral gastroenteritis often presents with symptoms like diarrhea, vomiting, stomach pain, and sometimes fever.
Frequent, watery diarrhea is a common characteristic of viral gastroenteritis in children.
The nurse should be aware of this symptom to provide appropriate care, including rehydration and monitoring for signs of dehydration.
Choice B rationale:
The statement, "No, my child's bowel movements are normal," would not be an expected response from the parent of a child with gastroenteritis.
As mentioned earlier, viral gastroenteritis typically causes changes in bowel habits, leading to frequent diarrhea.
Choice C rationale:
The statement, "My child has been constipated," is not consistent with the symptoms of gastroenteritis.
Constipation involves infrequent and difficult bowel movements, which are not typical symptoms of viral gastroenteritis.
Choice D rationale:
The statement, "My child has been vomiting a lot," is a symptom of gastroenteritis.
However, the question specifically asks about changes in bowel movements.
While vomiting is a common symptom of gastroenteritis, the focus here is on bowel movements, making choice A The correct answer.
The client reports, "My child has been vomiting and has stomach pain.”.
What is a potential statement the nurse might hear during the assessment?
Explanation
Choice D rationale:
The statement, "My child has had diarrhea for a few days," is a potential statement the nurse might hear during the assessment of a child with gastroenteritis.
Diarrhea is a common symptom of viral gastroenteritis and can lead to dehydration if not properly managed.
The nurse should assess the duration, frequency, and characteristics of the diarrhea to determine the severity of the condition and plan appropriate interventions.
Choice A rationale:
The statement, "My child has been eating and drinking normally," does not align with the symptoms described by the client.
Children with gastroenteritis often have decreased appetite and may not tolerate normal food and fluid intake due to nausea, vomiting, and diarrhea.
Choice B rationale:
The statement, "My child's bowel movements have been regular," contradicts the reported symptoms of diarrhea and stomach pain.
Regular bowel movements are not expected in a child with gastroenteritis, which commonly causes loose or watery stools.
Choice C rationale:
The statement, "My child hasn't had any abdominal discomfort," is not consistent with the typical symptoms of gastroenteritis.
Abdominal discomfort, cramping, and pain are common complaints in individuals with gastroenteritis, especially during episodes of diarrhea.
Select all that apply to effective prevention strategies.
Explanation
Choice A rationale:
Ensuring proper handwashing before meals and after using the toilet is an effective prevention strategy for gastroenteritis.
Proper hand hygiene helps prevent the spread of viral and bacterial infections, including those causing gastroenteritis.
Choice D rationale:
Advising parents to keep their child away