The nurse employed in an emergency department is monitoring a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the neck extended. How would the nurse interpret this finding? -

Extreme fatigue

An airway obstruction

Presence of pain

Presence of dehydration

Answer and Explanation

The Correct Answer is B

A. Extreme fatigue is not indicated by this positioning.

B. The child’s forward-leaning position with neck extension is a classic sign of epiglottitis, where the child is attempting to open the airway and facilitate breathing in response to obstruction.

C. Pain may be present, but the positioning is primarily related to an attempt to alleviate airway obstruction.

D. Dehydration would not typically cause this specific positioning.

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Correct Answer is D

Explanation

A. Foreign body aspiration is characterized by sudden onset of coughing, choking, and wheezing, not crackles and rales.

B. Systemic congestion refers to peripheral edema and does not usually present with crackles in the lungs.

C. Pneumonia would present with localized crackles or rales over specific lung areas and often includes fever and cough, which are not mentioned here.

D. Pulmonary congestion is common in children with VSD, particularly when the left side of the heart cannot effectively pump blood, leading to fluid accumulation in the lungs. Crackles and rales indicate this type of fluid buildup.

A. Aortic stenosis (AS) B. Transposition of the Great Vessels (Arteries) C. Coarctation of the Aorta (COA) D. Tetralogy of Fallot (TOF)

Correct Answer is C

Explanation

A. Aortic stenosis (AS) typically causes a difference in blood flow across the aortic valve but does not usually require assessment of upper and lower extremity blood pressures.

B. Transposition of the Great Vessels (Arteries) results in cyanosis and abnormal circulatory flow but does not require upper and lower extremity blood pressure monitoring.

C. Coarctation of the Aorta (COA) is characterized by narrowing of the aorta, often resulting in higher blood pressure in the upper extremities compared to the lower extremities. Measuring both helps identify this condition.

D. Tetralogy of Fallot (TOF) involves right ventricular outflow obstruction, VSD, overriding aorta, and right ventricular hypertrophy, but upper and lower extremity blood pressures are not typically used for diagnosis.

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The nurse employed in an emergency department is monitoring a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the neck extended. How would the nurse interpret this finding? -

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

In which congenital heart defect would the nurse need to take upper and lower extremity blood pressures?

Correct Answer is C

Explanation

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