A nurse is caring for a pre-school age child who has epiglottitis and presents with a high fever, drooling, and a muffled voice. Which of the following actions should the nurse take?
Use a tongue depressor to observe the epiglottis.
Initiate airborne precautions.
Monitor oxygen saturation.
Obtain a throat culture.
The Correct Answer is C
A. Using a tongue depressor can provoke spasm of the epiglottis and lead to airway obstruction; therefore, this action is contraindicated in a child with epiglottitis.
B. Airborne precautions are not necessary for epiglottitis; droplet precautions are more appropriate due to the risk of transmission.
C. Monitoring oxygen saturation is critical in this situation to assess the child's respiratory status and ensure adequate oxygenation, making it the most appropriate action.
D. Obtaining a throat culture may not be safe or practical in this scenario, as it can provoke further distress and complications; immediate assessment and stabilization are prioritized.
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Correct Answer is ["A","E","F"]
Explanation
A. Providing privacy during personal care and procedures is essential for adolescents, as it helps them feel more secure and respected during a vulnerable time.
B. This option is incorrect; discussing changes related to puberty can help the adolescent understand their body and promote healthy coping mechanisms.
C. Treating the adolescent as if they are not competent undermines their autonomy and can negatively impact their self-esteem; adolescents should be involved in their care and decision-making when appropriate.
D. Disregarding confidentiality can lead to a breakdown of trust; it is important to respect the adolescent's privacy while also keeping parents informed within appropriate limits.
E. Showing respect for the client's feelings and concerns helps validate their experiences and fosters a supportive environment during a challenging time.
F. Listening carefully to the client’s thoughts and concerns encourages open communication, allowing the nurse to address any worries and support the adolescent’s emotional needs.
Correct Answer is D
Explanation
A. Providing a lecture that encourages taking calculated risks may lead adolescents to underestimate the dangers of certain activities rather than promoting safety.
B. Offering rewards for reporting high-risk behavior may create an environment of distrust and could discourage open dialogue among peers regarding safety issues.
C. Giving pamphlets does not engage adolescents effectively; they may not read or absorb the information thoroughly without interactive discussion.
D. Creating a mock scene of a motor-vehicle crash effectively demonstrates the serious consequences of high-risk behaviors, engaging students in a way that promotes awareness and understanding of safety.