A nurse is assisting with the care of a preschooler who has epiglottitis. Which of the following actions should the nurse take?
Request an x-ray of the neck.
Monitor urine for protein.
Obtain a nasopharyngeal swab
Administer fluconazole.
The Correct Answer is A
A) Request an x-ray of the neck: In cases of suspected epiglottitis, a lateral neck x-ray can help confirm the diagnosis by showing the classic "thumbprint sign," which indicates swelling of the epiglottis. This is a critical diagnostic step, but it should only be performed in a controlled setting where the child’s airway can be monitored closely. The priority is to avoid any procedures that may cause irritation or further compromise the airway.
B) Monitor urine for protein: Monitoring urine for protein is not relevant to the management of epiglottitis. This condition is related to inflammation and obstruction of the upper airway, and the focus should be on respiratory management rather than renal function.
C) Obtain a nasopharyngeal swab: While obtaining a nasopharyngeal swab can help identify the organism causing an infection (often bacterial), it is not the immediate priority in a child with suspected epiglottitis. The child’s airway is the most critical concern, and diagnostic interventions that could potentially cause further distress or obstruction (such as swabbing) should be avoided until airway management is stable.
D) Administer fluconazole: Fluconazole is an antifungal medication, and its use is not appropriate for epiglottitis. Epiglottitis is most often caused by a bacterial infection, particularly Haemophilus influenzae type b (Hib), which requires antibiotic therapy, not antifungals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. "I can expect my contact lenses to turn red or orange.”
Rifampin causes red-orange discoloration of body fluids, including tears, sweat, urine, and saliva. This effect is harmless but can stain soft contact lenses permanently, so clients should be advised to use glasses instead.
B. “I should notify my provider if I start taking new over-the-counter or prescription medications.”
Rifampin is a potent enzyme inducer that can alter the metabolism of many drugs, including oral contraceptives and anticoagulants. The provider should be informed of any new medications to avoid potential drug interactions and ensure therapeutic effectiveness.
C. “I will need to have someone observe me when I take my medication.”
Directly observed therapy (DOT) is recommended to ensure adherence to tuberculosis treatment. A healthcare provider or designated individual supervises medication intake to improve compliance and reduce the risk of drug resistance.
D. “I will need to have a repeat Mantoux test in 4 weeks.”
A repeat Mantoux test is unnecessary for diagnosing active tuberculosis, as this condition is confirmed through sputum cultures and chest X-ray findings. Mantoux testing is primarily used for screening latent TB infections.
E. “I am no longer contagious.”
Clients with active tuberculosis remain contagious until they complete at least two weeks of effective multidrug therapy and show clinical improvement. Until then, infection control measures such as respiratory isolation should be followed.
F. “I will need to take my medications for a total of 6 weeks.”
The standard treatment for active tuberculosis lasts at least six months, typically involving a four-drug regimen for the first two months, followed by two drugs for the remaining four months. A six-week course is insufficient for eradication.
G. "I can continue my current alcohol intake."
Alcohol should be avoided due to the hepatotoxic effects of isoniazid, rifampin, and pyrazinamide. Combining alcohol with these medications increases the risk of liver damage, requiring clients to abstain or limit intake.
Correct Answer is C
Explanation
A) "I get nervous when I'm in a large group": This statement indicates social anxiety or discomfort, which is common among adolescents. While it may affect the client's well-being, it does not suggest an immediate risk for suicide.
B) "My partner and I had our first argument last night": While relationship issues can cause stress, this statement by itself does not indicate suicidal ideation. Arguments in relationships are a normal part of adolescent development and are not typically associated with a suicide risk unless other risk factors are present.
C) "I am not interested in anything anymore.": This is a concerning statement, as it suggests anhedonia, a hallmark symptom of depression. A lack of interest in activities once enjoyed, especially in adolescents, can be a significant risk factor for suicide and warrants further evaluation and intervention.
D) "I'm not sleeping much because of all the homework I have.": Although sleep disturbances can be a sign of stress, especially related to academic pressure, this is not an immediate indication of suicidal thoughts. Sleep issues can often be managed with lifestyle changes or stress management techniques.
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