Author Question: The nurse is assessing a 5-year-old girl who is anxious, has a high fever, speaks in a whisper, and ... (Read 46 times)

Garrulous · **on:** Jun 27, 2018

The nurse is assessing a 5-year-old girl who is anxious, has a high fever, speaks in a whisper, and sits up with her neck thrust forward. Based on these findings, the nurse would avoid which of the following interventions?

A) Providing 100 oxygen
B) Visualizing the throat
C) Allowing the child to sit up
D) Auscultating for lung sounds

Question 2

The nurse is taking a health history for a 4-year-old boy with fever, headache, and chest pain. This is his third episode of pneumonia in about 6 months. The nurse would anticipate further evaluation for which of the following?

A) Diabetes
B) Sickle cell anemia
C) Cerebral palsy
D) Asthma

tashiedavis420 · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

B
Response:
The child is experiencing signs and symptoms of epiglottitis, which can be life-threatening. Under no circumstances should the nurse attempt to visualize the throat. Reflex laryngospasm may occur, precipitating immediate airway occlusion. Providing 100 oxygen in the least invasive manner that is most acceptable to the child is a sound intervention, as is allowing the child to assume a position of sitting forward with the neck extended. Auscultation would reveal breath sounds consistent with an obstructed airway.

Answer to Question 2

D
Response:
Pneumonia is usually a self-limiting disease, but a child who presents with recurrent pneumonia should be evaluated for chronic lung disease such as asthma or cystic fibrosis. Evaluation for diabetes, sickle cell anemia, or cerebral palsy is unrelated to the child's recurrent pneumonia.