Which of the following is the most critical initial nursing action for a child suspected of epiglottitis?
Prepare for airway management.
Give racemic epinephrine.
Administer intravenous antibiotics.
Obtain a throat culture.
The Correct Answer is A
Choice A rationale
Epiglottitis is a rapidly progressive, life-threatening bacterial infection causing severe swelling of the epiglottis, potentially leading to acute, complete upper airway obstruction. The most critical initial nursing action is to minimize distress and be immediately prepared for definitive airway management (intubation or tracheostomy) by the appropriate team, as the airway can close suddenly.
Choice B rationale
Racemic epinephrine is an α-adrenergic agonist used to cause vasoconstriction and reduce subglottic edema, primarily indicated for croup. Epiglottitis involves supraglottic swelling, and while it may theoretically reduce edema, the primary risk is mechanical obstruction, making preparation for airway management the priority.
Choice C rationale
While prompt intravenous antibiotic administration is essential to treat the causative bacterium, usually Haemophilus influenzae type b, this action is secondary to securing a patent airway. A patient can die from asphyxiation much faster than from bacteremia, thus airway security must be addressed first.
Choice D rationale
Attempting to obtain a throat culture in a child with suspected epiglottitis is contraindicated. Any manipulation of the posterior pharynx or epiglottis, such as using a tongue blade or swab, can trigger laryngospasm and cause immediate, complete airway obstruction, which is a catastrophic complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Periorbital edema (swelling around the eyes) is a common sign of nephrotic syndrome or other systemic fluid overload states, such as congestive heart failure. While heart failure can be a complication of severe infective endocarditis (IE), periorbital edema is a non-specific finding and not a primary, classic physical finding of the infection itself.
Choice B rationale
Bounding pulses in the lower extremities are most characteristic of a condition causing a wide pulse pressure, such as a large patent ductus arteriosus (PDA) or aortic regurgitation. While aortic valve damage can occur in IE, the bounding pulse is not a hallmark finding directly resulting from the infectious process.
Choice C rationale
A high-pitched cry is a non-specific sign of neurological distress or pain in an infant. While systemic infection and potential septic emboli from infective endocarditis could affect the central nervous system, this symptom is not a primary or expected clinical manifestation of the localized heart valve infection.
Choice D rationale
Splinter hemorrhages are small, linear, dark-red streaks that appear under the nails. They are a classic peripheral sign of infective endocarditis caused by microemboli (tiny fragments of the infected vegetation) lodging in the distal capillaries of the nail bed, making this a highly indicative finding.
Correct Answer is B
Explanation
Choice A rationale
A mild headache is a very common and expected symptom following a concussion, resulting from the temporary biomechanical injury to brain tissue or surrounding structures. This symptom alone typically does not indicate an immediate neurological deterioration or an expanding intracranial lesion, provided it doesn't rapidly worsen in severity or become refractory to simple analgesics. Management generally involves rest and observation.
Choice B rationale
Vomiting, especially if persistent or projectile, suggests a significant increase in intracranial pressure (ICP) due to brain swelling or an intracranial hemorrhage. This pressure irritates the vomiting center in the medulla, a critical area of the brainstem. Given that normal ICP is 5-15 mmHg in adults and slightly lower in children, new or worsening emesis warrants prompt clinical and possibly neuroimaging reevaluation.
Choice C rationale
Alertness indicates an intact reticular activating system (RAS), which is crucial for consciousness. Maintaining an alert mental status is a positive sign that suggests the primary brain centers are functioning adequately and the ICP is not critically elevated. A decreased level of consciousness would be a much more concerning indicator of neurological decline.
Choice D rationale
A normal gait reflects proper coordination of motor, sensory, and cerebellar functions. Gross neurological integrity suggests that the cerebral and cerebellar pathways, which govern balance and movement, are not significantly compromised. An abnormal gait, like ataxia, would be a sign of focal neurological deficit or severe intracranial pressure.
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