A 2-year-old male child arrived in the Emergency Department with ...

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A 2-year-old male child arrived in the Emergency Department with complaints of sore throat, difficulty swallowing, and suspected diagnosis of acute epiglottitis.
 
  Which of the following interventions should not be included in the child's immediate care and assessment? 1. Vital signs
   2. Medical history
   3. Assessment of breath sounds
   4. Throat culture

Question 2

Which nursing assessment activities should be included for the child and family at each health supervision visit? Select all that apply.
 
  1. Interview to obtain an updated health history
 
  2. Performing an age-appropriate development assessment
 
  3. Monitoring parents' ability to pay for services
 
  4. Performing age-appropriate screening examinations
 
  5. Physical assessment for genetic abnormalities

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Answer to Question 1

4
Rationale:
1. Vital signs should always be taken when assessment is done.
2. Medical history should be obtained, which assists in diagnosis.
3. Assessment of breath sounds is essential for diagnosis.
4. Throat culture should never be done when a diagnosis of epiglottis is suspected. Manipulation of the throat can stimulate the gag reflex in an already inflamed airway, and can cause complete occlusion of the airway.

Answer to Question 2

1, 2, 4

Rationale:

1. The interview, the developmental assessment, and age-appropriate screenings all are included in the nursing assessment of a child and family during each health supervision visit.
2. The interview, the developmental assessment, and age-appropriate screenings all are included in the nursing assessment of a child and family during each health supervision visit.
3. A nurse would not assess the parents' financial status at each health supervision visit.
4. The interview, the developmental assessment, and age-appropriate screenings all are included in the nursing assessment of a child and family during each health supervision visit.
5. Physical assessments for genetic abnormalities would be done based on history and/or physical findings, not at each routine visit.