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","B","E"]
Explanation
A. Increased risk-taking behaviors are common as adolescents may feel invulnerable and engage in dangerous activities without considering the consequences.
B. Greater incidence of accidental injuries is often a result of risk-taking behaviors, which can be influenced by feelings of invulnerability.
C. Reduced mental health issues is incorrect as feelings of invulnerability can lead to increased stress and anxiety, negatively impacting mental health.
D. Improved social relationships are not guaranteed; feelings of invulnerability may actually lead to conflict or isolation if risk-taking behaviors are harmful.
E. Higher likelihood of substance abuse can result from a belief in invulnerability, leading adolescents to underestimate the risks associated with drug and alcohol use.
F. Enhanced academic performance is not directly linked to feelings of invulnerability and may suffer due to distractions from risky behaviors.
Correct Answer is D
Explanation
A. Encouraging excessive rest and avoidance of physical activities can lead to feelings of inferiority by limiting opportunities for achievement and social interactions.
B. Limiting social interactions is counterproductive, as friendships and peer relationships are critical for social development during this stage.
C. While supervision is important, overly controlling the child’s activities can inhibit their ability to explore and learn, negatively impacting their sense of industry.
D. Involving the child in decision-making and providing opportunities for independent tasks fosters a sense of competence and accomplishment, essential for developing a sense of industry, according to Erikson’s theory.