Which of the following are nursing priorities for a child with severe traumatic brain injury (TBI)?

Choice A rationale

Cyanosis, a bluish discoloration of the skin and mucous membranes, indicates significant hypoxemia (low oxygen saturation) and is a sign of severe, life-threatening asthma exacerbation, not a mild to moderate presentation. In mild to moderate asthma, the body can usually compensate to maintain adequate tissue oxygenation despite airway constriction and inflammation.

Choice B rationale

Chest tightness is a subjective but common symptom in asthma, resulting from the bronchoconstriction and smooth muscle spasm that narrow the airways. The sensation is often described as a band around the chest, reflecting the increased work of breathing and the mechanical effort required to move air through the restricted bronchial passages.

Choice C rationale

An asthma cough is typically non-productive (dry) or, if secretions are present, it is often a mucoid, tenacious sputum. A consistently productive cough suggests other underlying conditions, such as infection (e.g., pneumonia) or bronchiectasis, rather than being the hallmark of a primary, mild-to-moderate asthma flare.

Choice D rationale

Wheezing, a high-pitched whistling sound, is the classic objective sign of asthma, caused by the vibration of air attempting to move rapidly through the severely narrowed, obstructed small airways (bronchioles) during respiration. It is often most prominent on expiration but can be present on inspiration during a significant episode.

Choice E rationale

Prolonged expiration occurs because the narrowed, inflamed airways obstruct the outflow of air, leading to air trapping and a higher residual volume. The patient must forcefully and slowly push air out against the resistance, making the expiratory phase last significantly longer than the inspiratory phase, a key sign of obstructive lung disease.

Choice A rationale

Drooling is a hallmark sign of epiglottitis because the severe inflammation and swelling of the epiglottis make swallowing extremely painful. The child is reluctant to swallow their saliva, which pools in the mouth and causes characteristic drooling, indicating a critical impending airway obstruction.

Choice B rationale

A barking cough, often described as a "seal-like" cough, is the classic presentation of croup (laryngotracheobronchitis), which involves subglottic inflammation. Epiglottitis, in contrast, primarily involves supraglottic inflammation, leading to a blocked, or muffled, vocalization rather than the resonant, inspiratory stridor and cough of croup.

Choice C rationale

A muffled or "hot potato" voice is highly suggestive of epiglottitis. The swollen epiglottis and surrounding supraglottic structures impede the air column and vocal cord vibration, altering the quality of speech but allowing air to pass, unlike the near-complete aphonia seen in other laryngeal obstructions.

Choice D rationale

Wheezing is a high-pitched whistling sound typically heard on expiration, caused by the narrowing of the lower airways (bronchi/bronchioles), common in conditions like asthma or bronchiolitis. Epiglottitis is a supraglottic obstruction, manifesting predominantly as inspiratory stridor, not wheezing.

Choice E rationale

The tripod position (sitting upright, leaning forward with the neck hyperextended and chin thrust out) is adopted by children with epiglottitis to maximize the patency of the swollen airway and facilitate breathing. This is a sign of significant respiratory distress and impending airway failure.