A nurse is assessing a child with suspected epiglottitis.
Which clinical manifestation should the nurse prioritize when evaluating the severity of the condition?
"I can't swallow, and my throat hurts.”..
"I feel anxious and restless.”..
"I'm making a high-pitched sound when I breathe.”..
"My skin and lips look bluish.”..
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
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.
Correct Answer is B
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.