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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Option A (Place the infant in reverse Trendelenburg position) and option B (Place the infant in the knee to chest position) are not the immediate actions to address this situation. While these positions might be used in specific situations, assessing blood pressure is more appropriate in this context to evaluate for potential vascular issues.

Option C. Take the infant's blood pressure in all extremities.

In an infant with weaker femoral pulses compared to the brachial and radial pulses, there might be a concern about coarctation of the aorta (a narrowing of the aorta), which can affect blood flow to the lower extremities. To confirm this and assess for potential issues, taking blood pressure measurements in all four extremities is crucial. This comparison can help identify pressure differentials between the upper and lower extremities, which is a hallmark sign of coarctation of the aorta.

Option D (Notify the Physician) is generally a good step, but taking the blood pressure in all extremities should be done first to provide comprehensive information for the physician when discussing the infant's condition.

A. The body's response to gluten causes the intestine to become more porous and hang on to more of the fat-soluble vitamins, leading to vitamin toxicity." B. "The body's response to gluten causes damage to the mucosal cells in the intestines leading to absorption problems C. "The body's response to consumption of anything containing gluten is to create special cells called villi, which leads to more diarrhea D. "The body's response to gluten causes damage to the mucosal cells, leading to malabsorption of water and hard, constipated stools

Correct Answer is B

Explanation

A. "The body's response to gluten causes the intestine to become more porous and hang on to more of the fat-soluble vitamins, leading to vitamin toxicity." This answer is not accurate. The issue in celiac disease is malabsorption, not vitamin toxicity.

B. "The body's response to gluten causes damage to the mucosal cells in the intestines leading to absorption problems."

Celiac disease is an autoimmune disorder in which the ingestion of gluten (a protein found in wheat, barley, and rye) leads to damage of the mucosal cells in the small intestine. This damage, in turn, can lead to malabsorption of essential nutrients, including vitamins, minerals, and other important components of the diet. It is important for individuals with celiac disease to avoid gluten-containing foods to prevent ongoing damage to the intestinal mucosa and improve nutrient absorption.

C. "The body's response to consumption of anything containing gluten is to create special cells called villi, which leads to more diarrhea." This statement is not accurate. Celiac disease leads to damage to the villi (finger-like projections) in the small intestine, not the creation of special cells. It can lead to diarrhea but is not the primary cause.

D. "The body's response to gluten causes damage to the mucosal cells, leading to malabsorption of water and hard, constipated stools." This response is not accurate. Celiac disease is more commonly associated with diarrhea and malabsorption, not constipation and malabsorption of water.

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