110 - Nursing Exams Questions & Answers - Svastham Exemplar

 

Question 5476)

Which factor would most likely be a cause of epiglottitis? 

A. Acquiring the child’s first puppy the day before the onset of symptoms 

B. Exposure to the parainfluenza virus 

C. Exposure to Haemophilus influenzae, type B 

D. Frequent upper respiratory infections as an infant 

Answer: C 

Explanation: H. influenzae is the usual causative agent of epiglottitis. A puppy would be more apt to cause asthma than epiglottitis. 

Question 5477) 

The nurse is caring for a child who has epiglottitis. What position would the child be most likely to assume? 

A. Squatting 

B. Sitting upright and leaning forward, supporting self with hands 

C. Crouching on hands and knees and rocking back and forth 

D. Knee-chest position 

Answer: B 

Explanation: Sitting upright and leaning forward, supporting self with hands, is the position typically assumed by children with epiglottitis. It helps to promote the airway and drainage of secretions. Squatting is more typically seen in children who have cyanotic heart defects. 

Question 5478) 

The nurse is assessing a child who has epiglottitis and is having respiratory difficulty. Which of the following is the nurse most likely to assess in the child? 

A. Flaring of the nares; cyanosis; lethargy 

B. Diminished breath sounds bilaterally; easily agitated 

C. Scattered rales throughout lung fields; anxious and frightened 

D. Mouth open with a protruding tongue; inspiratory stridor 

Answer: D 

Explanation: The child with an edematous glottis will keep his mouth open with his tongue protruding to increase free movement in the pharynx. In the presence of potential laryngeal obstruction, laryngeal stridor can be heard, especially during inspiration. Rales and diminished breath sounds are more typical of croup. Cyanosis is typical of late-stage, extremely critical respiratory distress. 

Question 5479) 

Which of the following is the most important goal of nursing care in the management of a child with epiglottitis? 

A. Preventing the spread of infection from the epiglottis throughout the respiratory tract 

B. Reduction of high fever and prevention of hyperthermia 

C. Maintaining a patent airway 

D. Maintaining the child in an atmosphere of high humidity with oxygen 

Answer: C 

Explanation: In a child with epiglottitis, the first signs of difficulty in breathing can progress to severe inspiratory distress or complete airway obstruction in a matter of minutes or hours. The child usually has a high fever, but the airway takes precedence. High humidity may also be appropriate, but the highest priority is maintaining an airway. 

Question 5480) 

Which of the following is the most important nursing action when caring for a child with epiglottitis? 

A. Cardiac monitoring 

B. Blood pressure monitoring 

C. Temperature monitoring 

D. Monitoring intravenous infusion Answer: A Explanation: Regular monitoring of cardiac rate is essential because a rapidly rising heart rate is an initial indication of hypoxia and impending obstruction of the airway. The blood pressure and temperature may well be monitored, but they are not the most important. An IV will be monitored, if present, but is not the highest priority.