A nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse take
Obtain a throat culture.
Visualize the epiglottis with a tongue depressor
Place the child in an upright position
Transport the child to radiology for a throat x-ray
The Correct Answer is C
A. Obtaining a throat culture and B. visualizing the epiglottis with a tongue depressor are not safe actions for the nurse to perform without appropriate medical equipment and expertise. These actions can trigger a sudden airway obstruction in a child with epiglottitis. The priority is to ensure airway patency and seek immediate medical assistance.
C. Place the child in an upright position.
Suspected epiglottitis is a medical emergency that can result in rapid airway obstruction. Placing the child in an upright position helps improve airflow by allowing the throat to open and reduces the risk of complete airway obstruction. It's important not to perform invasive procedures (such as throat culture or visualization of the epiglottis) without proper medical equipment and expertise, as these actions can lead to worsening airway obstruction.
D. Transporting the child to radiology for a throat x-ray is not appropriate in this situation, as it may delay necessary interventions to secure the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Insulin is responsible for lowering blood glucose levels by promoting the uptake and storage of glucose in cells.
B. Epinephrine (adrenaline) can raise blood glucose levels in response to the "fight or flight" stress response, but it's not primarily responsible for stimulating liver glycogenolysis.
C. Glucagon is produced by the alpha cells in the islets of Langerhans and plays a crucial role in increasing blood glucose levels. It promotes the breakdown of glycogen (glycogenolysis) in the liver and the production of glucose from non-carbohydrate sources (gluconeogenesis).
D. Adrenocorticotropic hormone (ACTH) is produced by the anterior pituitary gland and stimulates the adrenal cortex to release cortisol, which can also contribute to raising blood glucose levels but isn't primarily responsible for liver glycogenolysis.
In the context of diabetes management, understanding the role of glucagon is important because it helps individuals know how to manage hypoglycemia (low blood sugar) by administering glucagon or consuming fast-acting sources of glucose.
Correct Answer is A
Explanation
A. A fontanelle that bulges with crying.
Myelomeningocele is a congenital neural tube defect that involves the spinal cord. It is associated with an increased risk of hydrocephalus, which can lead to increased intracranial pressure (ICP). The fontanelle (soft spot) on an infant's head can provide insight into ICP. When an infant with myelomeningocele has an increase in intracranial pressure, the fontanelle may bulge, especially when the infant cries. This is due to the buildup of cerebrospinal fluid within the skull.
B. Increased respiratory rate: While increased intracranial pressure can affect various body systems, an increased respiratory rate is not a specific sign of ICP associated with myelomeningocele.
C. A high-pitched cry: A high-pitched cry is not typically associated with increased intracranial pressure in the context of myelomeningocele. Signs of ICP in infants may include irritability, lethargy, vomiting, and changes in head circumference.
D. Tachycardia: Tachycardia can be a response to stress or discomfort in an infant, but it is not a specific indicator of increased intracranial pressure related to myelomeningocele.
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