A nurse is assessing a child who has been brought to the clinic with symptoms of tonsillitis.
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:.
The nurse should assess for drooling.
The nurse should assess for earache.
The nurse should assess for neck stiffness.
The nurse should assess for increased energy levels.
The nurse should assess for vomiting.
Correct Answer : A,B,C
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
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.
Correct Answer is B
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.
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