A nurse is caring for a pre-school age child who has epiglottitis and presents with a high fever, drooling, and a muffled voice. Which of the following actions should the nurse take?

Use a tongue depressor to observe the epiglottis.

Initiate airborne precautions.

Monitor oxygen saturation.

Obtain a throat culture.

Answer and Explanation

The Correct Answer is C

A. Using a tongue depressor can provoke spasm of the epiglottis and lead to airway obstruction; therefore, this action is contraindicated in a child with epiglottitis.

B. Airborne precautions are not necessary for epiglottitis; droplet precautions are more appropriate due to the risk of transmission.

C. Monitoring oxygen saturation is critical in this situation to assess the child's respiratory status and ensure adequate oxygenation, making it the most appropriate action.

D. Obtaining a throat culture may not be safe or practical in this scenario, as it can provoke further distress and complications; immediate assessment and stabilization are prioritized.

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Correct Answer is ["C","D","E"]

Explanation

A. Pertussis primarily affects the respiratory tract rather than just the nostrils.

B. Pertussis is caused by the bacterium Bordetella pertussis, making it a bacterial infection, not viral.

C. The bacteria release toxins that damage the cilia of the epithelial cells in the respiratory tract, disrupting their function.

D. Inflammation occurs in the lungs and airway due to the infection, contributing to symptoms such as cough.

E. The infection leads to excessive secretions that are difficult to expel, resulting in the characteristic whooping cough associated with pertussis.

A. Encourage the adolescent to spend more time alone to build self-confidence. B. Assign the adolescent as the leader of a group project in a school activity. C. Arrange one-on-one counseling sessions to explore the causes of social withdrawal. D. Advise the adolescent to focus solely on academic achievements to boost self-esteem.

Correct Answer is C

Explanation

A. Encouraging the adolescent to spend more time alone may reinforce their withdrawal and does not promote social interaction or engagement.

B. Assigning the adolescent as a leader may increase anxiety and exacerbate their withdrawal rather than encourage socialization.

C. One-on-one counseling can provide a safe space for the adolescent to express feelings and explore the reasons for their withdrawal, which is a supportive and therapeutic intervention.

D. Focusing solely on academic achievements may lead to further isolation and does not address the need for social skills development and peer interaction.

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A nurse is caring for a pre-school age child who has epiglottitis and presents with a high fever, drooling, and a muffled voice. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who is suspected of having pertussis. The nurse should recognize that the pathophysiology of pertussis includes which of the following?

Correct Answer is ["C","D","E"]

Explanation

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Correct Answer is C

Explanation

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