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 D
Explanation
A. While anxiety and withdrawal are concerning, they may not require immediate intervention compared to behaviors that pose risks to the child or others.
B. A stable child with a concerned parent may benefit from reassurance and support, but they do not require urgent intervention.
C. Stomach pain without an apparent cause should be assessed, but it may not be as urgent as aggressive behavior that can harm others.
D. A child exhibiting aggressive behavior poses a risk to themselves and others, necessitating immediate assessment and intervention to ensure safety and manage the behavior effectively.
Correct Answer is D
Explanation
A. The ASO titer does not measure therapeutic levels of aminoglycosides; this response is incorrect.
B. The ASO titer is not a direct diagnostic test for rheumatic fever but indicates a recent infection with streptococcal bacteria, which can lead to rheumatic fever.
C. The test does not confirm immunity but rather measures antibodies against streptolysin O, indicating recent infection.
D. An elevated ASO titer confirms that the child had a recent streptococcal infection, which is important in diagnosing rheumatic fever.