Which assessment is of greatest concern in a 15-month-old?

The child is lying down and has moderate retractions, low-grade fever, and nasal congestion.

The child is in the tripod position and has diminished breath sounds and a muffled cough.

The child is sitting up and has coarse breath sounds, coughing, and fussiness.

The child is restless and crying, has bilateral wheezes, and is feeding poorly.

Answer and Explanation

The Correct Answer is B

Acute epiglottitis is a medical emergency most often caused by Haemophilus influenzae type B (Hib). It results in rapid swelling of the epiglottis, leading to airway obstruction. Typical presentation includes sudden onset of high fever, drooling, severe sore throat, dysphagia, muffled voice, stridor, tripod positioning, absence of cough, anxiety and restlessness due to respiratory distress.

Rationale for correct answer:

2. The child is in the tripod position and has diminished breath sounds and a muffled cough: This finding indicates severe airway obstruction and impending respiratory failure. Tripod position and muffled cough are hallmark signs of epiglottitis. Diminished breath sounds signal that air movement is critically reduced, a life-threatening emergency requiring immediate airway management and preparation for intubation. The child should not be examined or agitated; emergency airway equipment should be ready, and the provider notified immediately.

Rationale for incorrect answers:

1. The child is lying down and has moderate retractions, low-grade fever, and nasal congestion: This is consistent with nasopharyngitis (common cold) or mild upper respiratory infection, not an emergency. The airway is patent.

3. The child is sitting up and has coarse breath sounds, coughing, and fussiness: These findings are more consistent with bronchiolitis or viral croup, which cause airway inflammation but typically have a characteristic cough and coarse sounds, not a muffled voice or tripod positioning.

4. The child is restless and crying, has bilateral wheezes, and is feeding poorly: This presentation suggests asthma or reactive airway disease, not epiglottitis. While concerning, wheezing indicates air is still moving, unlike the silent chest seen in impending obstruction from epiglottitis.

Take home points

Tripod position, muffled voice, and diminished breath sounds signify airway emergency.
Do not attempt throat inspection or use a tongue blade since this can trigger complete obstruction.
Keep emergency intubation and tracheostomy equipment ready at the bedside.
Calm the child, avoid unnecessary interventions, and notify the provider immediately.

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Correct Answer is B

Explanation

Epiglottitisis a life-threatening bacterial infection—most commonly due to Haemophilus influenzae type B (Hib), that causes inflammation and swelling of the epiglottis, leading to airway obstruction. Typical presentation includes sudden onset of high fever, drooling, severe sore throat, dysphagia, muffled voice, stridor, tripod positioning, absence of cough, anxiety and restlessness due to respiratory distress.

Rationale for correct answer:

2. A 6-year-old who has high fever, no spontaneous cough, and frog-like croaking: These are classic signs of acute epiglottitis and signal imminent airway obstruction. The absence of a cough differentiates it from croup, and the frog-like croak indicates severe upper airway involvement. The child is in extreme danger of airway closure and requires immediate airway management and emergency medical treatment, often including intubation or tracheostomy and IV antibiotics.

Rationale for incorrect answers:

1. A 3-year-old who has a barky cough, is afebrile, and has mild intercostal retractions: This presentation is typical of mild viral croup (laryngotracheobronchitis). The child is stable and can usually be managed with humidified air or nebulized epinephrine, not an emergency.

3. A 7-year-old who has abrupt onset of moderate respiratory distress, a mild fever, and a barky cough: Although the child has distress, the presence of a barky cough indicates croup, not epiglottitis. Treatment includes corticosteroids and nebulized epinephrine, but it’s not as emergent as airway obstruction from epiglottitis.

4. A 13-year-old who has a high fever, stridor, and purulent secretions: This presentation suggests bacterial tracheitis, a serious but slower-progressing condition than epiglottitis. Requires IV antibiotics and airway monitoring, but it does not progress to complete airway obstruction as rapidly as epiglottitis.

Take home points

Epiglottitis is an emergency. Look for high fever, drooling, no cough, muffled or croaking voice.
Never attempt to examine the throat since this may trigger complete airway obstruction.
Immediate airway stabilization and IV antibiotics are priorities.
Rapid recognition and intervention are life-saving in epiglottitis.

A. Cool mist tent B. Intubation equipment C. Tongue blades D. Viral culture medium

Correct Answer is B

Explanation

Acute epiglottitisis a medical emergencycaused primarily by Haemophilus influenzae type B (Hib)infection. The inflamed epiglottis can rapidly swell, leading to sudden and complete airway obstruction.

Typical presentation includes sudden onset of high fever, drooling, severe sore throat, dysphagia, muffled voice, stridor, tripod positioning, and absence of cough.

Rationale for correct answer:

2. Intubation equipment: The nurse must have intubation or tracheostomy equipment immediately available when examining a child with suspected epiglottitis. The airway can obstruct suddenly and completely, even with minimal stimulation. Intubation should be performed only by an experienced provider (e.g., anesthesiologist, critical care physician) in a controlled environment. Equipment should include an appropriate-size endotracheal tube, laryngoscope, suction setup, and emergency tracheostomy kit.

Rationale for incorrect answers:

1. Cool mist tent: Humidified air may provide comfort in mild respiratory conditions (e.g., croup), but in epiglottitis, it is not the priority. Airway maintenance supersedes all comfort measures.

3. Tongue blades: Using a tongue blade to inspect the throat can trigger laryngospasm or complete airway obstruction. The throat must never be examined until airway control is secured.

4. Viral culture medium: Epiglottitis is caused by a bacterial pathogen, not a virus, so viral cultures are unnecessary and would delay emergency treatment.

Take home points

Always have emergency airway equipment ready when epiglottitis is suspected.
Never attempt to visualize the throat or insert objects into the mouth.
Do not leave the child unattended. Always keep the parent nearby to reduce anxiety.
Prepare for immediate intubation and administer I.V. antibiotics once the airway is secure.

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Which assessment is of greatest concern in a 15-month-old?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which child is in the greatest need of emergency medical treatment?

Correct Answer is B

Explanation

While examining a child with acute epiglottitis, a nurse should have which item available?

Correct Answer is B

Explanation

What should be the nurse’s first action with a child who has a high fever, dysphagia, drooling, tachycardia, and tachypnea?

A child with difficulty breathing and a “barking cough’ is displaying signs associated with which condition?

Which is the nurse’s best response to the parent of a child diagnosed with epiglottitis who asks what the treatment will be?

During the recovery stages of croup, a nurse should explain which intervention to parents?

A 4-year-old female child presents to the emergency department with a sore throat, difficulty swallowing, and a suspected diagnosis of acute epiglottitis. Which information should be included in the initial assessment of the child? Select all that apply

A 2-year-old child is brought to the emergency department in respiratory distress. The child is drooling, sitting upright and leaning forward with chin thrust out, mouth open, and tongue protruding. Which nursing intervention is most appropriate?

The parent of a child with croup tells the nurse that her other child just had croup and it cleared up in a couple of days without intervention. She asks the nurse why this child is exhibiting worse symptoms and needs to be hospitalized. Which is the nurse’ s best response?

Which instruction should a nurse give the parents of a 2-year-old child who wakes in the night with a barking cough?