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 C
Explanation
Choice A reason: This is not the correct answer because infant bones are not prone to fractures. They are more flexible and resilient than adult bones, and require more force to break.
Choice B reason: This is not the correct answer because the focus should not be only on the injury, but also on how it occurred. The nurse should assess the mechanism of injury and the history of the child and the family for any signs of abuse or neglect.
Choice C reason: This is the correct answer because inconsistencies in how injury occurred may indicate child maltreatment. The nurse should be alert for any discrepancies or changes in the story, or any explanations that do not match the type or severity of the injury.
Choice D reason: This is not the correct answer because parents don't necessarily forget details when they are under stress. They may be anxious or emotional, but they should still be able to provide a consistent and coherent account of what happened.
Correct Answer is D
Explanation
Choice A reason: This response is not the priority action because dehydration is not an immediate threat to the child's life. The nurse should first rule out any signs of hemorrhage, which is a common complication of tonsillectomy.
Choice B reason: This response is not the priority action because pain medication may mask the symptoms of bleeding, such as increased swallowing or restlessness. The nurse should first assess the child for any signs of hemorrhage, and then administer pain medication as needed.
Choice C reason: This response is not the priority action because cherry popsicles may irritate the throat and cause bleeding. The nurse should first assess the child for any signs of hemorrhage, and then offer clear fluids or ice chips to the child.
Choice D reason: This response is the priority action because post-op bleeding is a serious and potentially fatal complication of tonsillectomy. The nurse should assess the operative site for any signs of bleeding, such as fresh blood, clots, or increased swallowing. The nurse should also monitor the child's vital signs, oxygen saturation, and level of consciousness. If bleeding is suspected, the nurse should notify the physician immediately and prepare for emergency interventions.
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