Exhibits

A nurse is collecting data from an adolescent who has a new diagnosis of infectious mononucleosis. Which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Rationale:

• Type of cough: The characteristic "barking" cough is typical of acute laryngotracheobronchitis (also known as croup), which affects the upper airways and results in a harsh, barking cough. Pneumonia causes a productive cough, which is not noted here. The non-productive cough in this case is more indicative of laryngotracheobronchitis.
• Fever: A low-grade fever is common in acute laryngotracheobronchitis and is consistent with this case (38.2°C to 38.9°C). Pneumonia can also cause fever, especially a higher-grade fever, but the fever.
• Stridor: Inspiratory stridor is a hallmark sign of acute laryngotracheobronchitis, caused by narrowing of the upper airway, leading to a high-pitched sound when breathing in. Stridor is not typically associated with pneumonia, as pneumonia primarily affects the lungs and causes symptoms like cough, difficulty breathing, and chest pain rather than airway narrowing.
• Irritability: Irritability is common in acute laryngotracheobronchitis due to discomfort from the cough, difficulty breathing, and fever. Irritability can also be seen in pneumonia, particularly in young children who may be uncomfortable due to fever, difficulty breathing, and general malaise.

Rationale for Correct Choices:

• Administer anticonvulsant: Since the adolescent is having symptoms that precede a seizure (blurred vision), administering an anticonvulsant as prescribed can help prevent or reduce seizure activity.
• Place the client lying on the side: Lying on the side ensures an open airway and reduces the risk of aspiration during a seizure. This position also allows secretions to drain safely.

Rationale for Incorrect Choices:

• Place a tongue blade in the client’s mouth: A tongue blade can cause injury to the teeth or mouth and increase choking risk. The proper approach is to place the client on their side and avoid putting objects in their mouth.
• Restrict movement in the extremities: Restricting movement could cause injury. The focus should be on safety by allowing the seizure to occur without interference while monitoring vital signs and activity.