During the nursing assessment of a child with suspected epiglottitis, the nurse observes that the child is drooling and has difficulty managing secretions.
Which statement made by the child would be most concerning for the nurse?
"My throat is really sore.”..
"I can't stop drooling.”..
"I feel restless and agitated.”..
"I'm having trouble breathing.”..
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Choice A rationale:
Tracheostomy may be necessary in severe cases of epiglottitis where the airway obstruction is life-threatening and cannot be managed with other interventions.
In such cases, creating a surgical airway via tracheostomy can provide a more stable and secure airway, ensuring adequate oxygenation.
However, this option is typically considered when other measures, such as intubation, have failed or are not feasible due to the severity of the obstruction.
Choice B rationale:
Intubation may be required in cases where the airway obstruction is significant, and the child is unable to maintain oxygenation and ventilation adequately.
Intubation allows for mechanical ventilation, ensuring a patent airway and adequate oxygen supply.
However, it is not always the only option and may depend on the severity of the condition and the response to other interventions.
Choice C rationale:
Tracheostomy is more invasive than intubation.
While tracheostomy is a surgical procedure that involves creating an opening in the trachea, intubation involves inserting a tube through the mouth or nose into the trachea.
Tracheostomy is considered more invasive because it requires a surgical incision and the placement of a permanent or temporary tracheostomy tube.
Choice D rationale:
Intubation is not always the first choice for airway management in epiglottitis.
The choice of airway management (intubation, tracheostomy, or other interventions) depends on the severity of the airway obstruction, the child's clinical condition, and the healthcare provider's assessment.
Intubation may be chosen if the obstruction is significant and the child cannot maintain adequate oxygenation and ventilation.
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