The nurse is assessing a child with epiglottitis in the emergency department. The child has a sore throat and is drooling. Examining the child's throat using a tongue depressor might precipitate which of the following?
Respiratory tract infection
Sore throat
Complete airway obstruction
Inspiratory stridor
The Correct Answer is C
Choice A reason: Respiratory tract infection is not a correct answer because it is not a complication of examining the child's throat. It is a possible cause of epiglottitis, which is an inflammation of the epiglottis, the flap that covers the entrance to the trachea.
Choice B reason: Sore throat is not a correct answer because it is not a complication of examining the child's throat. It is a symptom of epiglottitis, along with fever, difficulty swallowing, and drooling.
Choice C reason: Complete airway obstruction is the correct answer because it is a life-threatening complication of examining the child's throat. The tongue depressor can trigger a spasm of the epiglottis, which can block the airway and cause respiratory distress or arrest.
Choice D reason: Inspiratory stridor is not a correct answer because it is not a complication of examining the child's throat. It is a sign of upper airway obstruction, which can occur in epiglottitis, but it is not caused by the tongue depressor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the most comprehensive and accurate way of assessing a child's pain, as it takes into account the child's own perception, the parent's observation, and the objective signs of pain.
Choice B reason: This is not the best approach, as the parents may not be able to accurately rate the child's pain, especially if the child is too young or has communication difficulties.
Choice C reason: This is not the best approach, as behavioral clues may not always reflect the intensity or quality of pain, and may be influenced by other factors such as fear, anxiety, or coping strategies.
Choice D reason: This is not the best approach, as physiological measures may not always correlate with pain, and may be affected by other variables such as medication, stress, or illness.
Correct Answer is C
Explanation
Choice A reason: This is not a relevant question for the admission history, as it does not address the child's current condition or treatment plan. It may also be perceived as insensitive or judgmental by the parents.
Choice B reason: This is not a pertinent question for the admission history, as it does not relate to the child's medical history or needs. It may also be seen as intrusive or irrelevant by the parents.
Choice C reason: This is an appropriate question for the admission history, as it acknowledges the cultural beliefs and practices of the parents and the child. It also helps the nurse to identify any potential interactions or conflicts between the tribal healer's recommendations and the medical treatment.
Choice D reason: This is a valid question for the admission history, as it informs the nurse of any alternative therapies or substances that the child may have received or ingested. It also helps the nurse to assess the effectiveness and safety of the herbal remedies, and to prevent any adverse effects or interactions with the prescribed medications.
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