NCLEX Pediatric: EENT Questions
Pediatric: EENT NCLEX Practice Questions
Question 1.
The recovery room nurse is caring for a 9-year-old girl who is recovering from tonsillectomy. The child is sleepy but easily awakened. The nurse knows the child should be placed in which position?
(a) Supine
(b) Side-lying
(c) Prone
(d) Sims’
Answer:
(b) Side-lying
Explanation:
Tonsillectomy is an outpatient procedure performed to remove the tonsils due to recurrent tonsillitis, airway obstruction, or debris (tonsil stones). The patient is at risk for bleeding in the throat immediately following the surgery, so keeping the airway patent and facilitating oral drainage is most important.
Side-lying is the best position to place the child. The nurse should frequently monitor vital signs, watching especially for decreasing blood pressure and increasing heartrate. Bright red blood in the back of the throat is another sign of hemorrhage.
Rationale:
(a) is incorrect because if the patient experiences bleeding in the throat, supine position could lead to bleeding into the airway.
(c) is incorrect because prone position is inappropriate as it does not facilitate easy breathing after surgery.
(d) is incorrect because Sims’ position is for administration of an enema.
Question 2.
The nurse in the clinic is preparing to instill antibiotic eyedrops in a 12- year-old boy with bacterial conjunctivitis. In order to avoid systemic adverse effects from the medication, which of the following does the nurse perform?
(a) Apply pressure on the eyelid rim
(b) Apply pressure on the inner canthus
(c) Place the child supine after instillation
(d) Have the child close their eyes tightly
Answer:
(b) Apply pressure on the inner canthus
Explanation:
Conjunctivitis, or pinkeye, is erythema and swelling of conjunctiva due to infection with a virus or bacteria and is highly contagious. Only bacterial conjunctivitis is treated with antibiotic eye drops. After the eyedrops are instilled, the child closes their eyes gently, and light pressure is applied to the inner canthus for a couple of minutes to prevent the medication from being absorbed systemically.
Rationale:
(a) is incorrect because applying pressure on the eyelid rim will not prevent systemic absorption. This will prevent the medication from washing over the surface of the eye and prevent the full effect of the medication.
(c) is incorrect because placing the child supine will not prevent systemic absorption but may cause the eyedrops to leak out of the lateral surfaces of the eyes.
(d) is incorrect because having the child close their eyes tightly will cause the eyedrops to be expressed from the eyes and run down the cheeks. This will prevent the medication from having the desired antibacterial effect on the infected eyes.
Question 3.
The nurse in the clinic is caring for a 7-year-old girl experiencing epistaxis. The nurse performs which of the following interventions?
(a) Performs abdominal thrust maneuver (Heimlich)
(b) Applies ice collar to neck
(c) Compresses nares to septum for at least 5 minutes
(d) Encourages throat gargles with warm saline
Answer:
(c) Compresses nares to septum for at least 5 minutes
Explanation:
Epistaxis is a nosebleed and can either be anterior or posterior, depending on where mucosa has been eroded and blood vessels are exposed. Compressing the nares to the septum for at least 5 minutes places pressure on the exposed blood vessel and stops bleeding.
Rationale:
(a) is incorrect because the Heimlich maneuver is for foreign object removal from the airway and may worsen epistaxis.
(b) is incorrect because an ice collar applied to the neck will not relieve epistaxis.
(d) is incorrect because throat gargles with warm saline are appropriate after epistaxis is resolved but will not relieve epistaxis and are, therefore, not the best nursing action.
Question 4.
A 5-year-old boy is in the clinic complaining of ear pain. When assessing the child, which of the following findings would alert the nurse to consider serous otitis media?
(a) Inflammation of the external ear and crust on the auditory canal
(b) Sensorineural hearing loss and tinnitus
(c) Plugged feeling in ear and reverberation of child’s own voice
(d) Tympanic membrane is bright red and bulging or retracted and fever
Answer:
(c) Plugged feeling in ear and reverberation of child’s own voice
Explanation:
Serous otitis media occurs when the eustachian tube is blocked from a nasal allergy attack or upper respiratory infection, causing fluid collection in the middle ear. The child will experience a plugged feeling in the ear and hear their own voice reverberating due to the fluid collection.
Rationale:
(a) is incorrect because inflammation of the external ear is otitis externa.
(b) is incorrect because sensorineural hearing loss and tinnitus are due to inner ear damage, which can be a long-term detrimental result from untreated otitis media.
(d) is incorrect because an inflamed tympanic membrane with fever is myringitis.
Question 5.
A 9-year-old girl in the clinic has been diagnosed with strep throat. When assessing the child, which findings does the clinic nurse expect to find?
(a) Weak cough and high-pitched noise with respirations
(b) Foul breath and noisy respirations
(c) Pain over sinus areas and purulent nasal secretions
(d) Bright red pharynx and fever
Answer:
(d) Bright red pharynx and fever
Explanation:
Strep throat is a bacterial streptococcal infection of the throat. The throat becomes bright red and raw with or without white or yellow spots, and the child will complain of pain when swallowing. Tonsils and lymph nodes become swollen, and the child will have a fever with this diagnosis.
Rationale:
(a) is incorrect because strep throat does not cause a weak cough or high- pitched noise with respiration. Weak cough may be an indication of a child who is lethargic or has impaired respiratory muscles, and high- pitched noises may indicate narrowing of the airways, which is not common with strep throat.
(b) is incorrect because strep throat may cause foul breath but does not commonly cause noisy respirations. Noisy respirations can be an indication of croup (presents with inspiratory stridor) or constricted airway channels and should be investigated further by the nurse.
(c) is incorrect because strep throat does not cause sinus pain or purulent nasal secretions. These are symptoms of a sinus infection.
Question 6.
A 5-year-old female child is in the emergency room for an item lodged in the left ear. The parent states that it may be a mosquito. Which of the following nursing actions is best?
(a) Irrigation of the ear with warm water
(b) Instillation of diluted alcohol
(c) Instillation of antibiotic ear drops
(d) Instillation of corticosteroid ear drops
Answer:
(b) Instillation of diluted alcohol
Explanation:
Insects in the ear are typically killed with instillation of diluted alcohol, unless a flashlight or humming noise coaxes them out. The diluted alcohol is instilled to suffocate the insect, which can then be removed from the ear with forceps.
Rationale:
(a) is incorrect because irrigation of the ear with water can be detrimental to the child if the object is a piece of food (beans, seeds, and small vegetables will swell with water irrigation, making them more difficult to remove from the ear). If the nurse visualizes an insect in the ear, water, mineral oil, or alcohol can be instilled to suffocate the insect.
(c) is incorrect because antibiotic ear drops will not remove an insect and are not necessary unless signs of infection are present. The insect would be removed from the ear first (with oil or alcohol), and then the infection can be treated.
(d) is incorrect because corticosteroid ear drops will not remove an insect and are usually not necessary. (It is important for the nurse to use non- pharmacologic measures when possible.)
Question 7.
A 7-year-old boy is in the clinic complaining of ear pain. The nurse questions orders for ear canal irrigation in which of the following circumstances?
(a) Wax buildup
(b) Hearing loss
(c) Otitis externa
(d) Perforated tympanic membrane
Answer:
(d) Perforated tympanic membrane
Explanation:
Irrigation of the ear canal when the tympanic membrane is perforated is contraindicated as fluid can enter the inner ear, causing dizziness, infection, nausea, and vomiting.
Rationale:
(a) is incorrect because ear pain could be due to cerumen impaction, which maybe irrigated.
(b) is incorrect because hearing loss could be due to cerumen impaction, which may be irrigated.
(c) is incorrect because otitis externa is due to either infection or cerumen impaction, which may be irrigated.
Question 8.
The school nurse is preparing to perform a hearing assessment on a 10- year-old girl. When performing the whispered voice test, which of the following is the correct method for performing the test?
(a) Stand 4 feet away from the child to ensure the child can hear from this distance.
(b) Stand 1-2 feet in front of the child, whisper, a statement and have the child repeat it.
(c) Whisper a statement with the nurse’s back facing the child.
(d) Stand 1-2 feet behind the patient, have the child plug one ear, whisper three letters or numbers, and have the child repeat the sequence.
Answer:
(d) Stand 1-2 feet behind the patient, have the child plug one ear, whisper three letters or numbers, and have the child repeat the sequence.
Explanation:
This is the proper method for performing the voice hearing assessment. The process is then repeated using a different letter or number sequence with the patient’s other ear blocked.
Rationale:
(a) is incorrect because standing 4 feet away is not the correct distance for performing the voice hearing assessment.
(b) is incorrect because standing in front of the child does not prevent lip-reading.
(c) is incorrect because the nurse’s back should not be facing the child. The nurse should stand 1-2 feet behind the patient, facing the patient’s back.
Question 9.
The nurse has received orders for instillation of cortisporin suspension, 2 ,gtts right ear, for an 8-year-old boy in the clinic. Which of the following interventions is essential for the nurse to perform?
(a) Verify correct patient and route
(b) Warm the solution before instilling, to prevent dizziness
(c) Hold an emesis basin under the child’s ear
(d) Position the child in semi-Fowler’s
Answer:
(a) Verify correct patient and route
Explanation:
The nurse always follows the five rights of medication administration, which begins with verifying the correct patient and route. Two forms of patient identifier must be used.
Rationale:
(b) is incorrect because the solution may be instilled at room temperature.
(c) is incorrect because an emesis basin under the ear is used for irrigation. When administering 2 gtts into the ear, the nurse would not anticipate anything to drain out of the ear.
(d) is incorrect because the child should be placed in a side-lying position, not semi-Fowler’s.
Question 10.
The nurse in the clinic is assessing a 12-month-old child with cleft palate who is awaiting surgical repair in 2 weeks. The nurse knows the child is at increased risk for otitis media due to:
(a) Lowered resistance to infection due to decreased nutritional intake
(b) Dysfunction of eustachian tubes
(c) Eustachian tube plugging with food particles
(d) Middle ear congenital defects
Answer:
(b) Dysfunction of eustachian tubes
Explanation:
Cleft palate is a congenital defect that affects the palate, or roof of mouth, and prevents tissue from completely closing in utero, leaving an opening between the roof of the mouth and the nasal passage.
The eustachian tubes may also be dysfunctional or ineffective due to the structural defect, putting the child at increased risk for otitis media. Cleft palate is often repaired between the ages of 12 and 18 months.
Rationale:
(a) is incorrect because children with cleft palate do not necessarily have altered nutrition. Parents should be taught that these babies often take longer to feed and need adequate time to finish meals. Soft nipple may be needed for bottle-feeding, and they should be burped often.
(c) is incorrect because food does not commonly enter the eustachian tube through the cleft palate.
(d) is incorrect because cleft palate and congenital middle ear deformities are not associated.
Question 11.
The nurse in the newborn nursery is assessing an infant who has a cleft lip. Which of the following nursing actions is best?
(a) Assessing sucking ability
(b) Monitoring for adequate diaphragmatic movement
(c) Encouraging locomotion
(d) Administering ranitidine to promote GI function
Answer:
(a) Assessing sucking ability
Explanation:
Cleft lip is a congenital defect that affects the upper lip and prevents tissue from completely joining in utero, leaving a separated upper lip that may affect the nose as well. Assessing sucking ability is the nurse’s greatest priority as it directly impacts the infant’s nutritional needs. The , infant will have difficulty with sucking, and devices may be required to allow the infant to feed adequately and be gratified by sucking.
Rationale:
(b) is incorrect because cleft lip does not affect movement of the diaphragm. Respiratory status should be monitored closely, however, especially during feeding, when the infant is more at risk for aspiration.
(c) is incorrect because cleft lip does not affect locomotion. The primary concern is ability to suck and swallow and maintain airway during feedings. This is more important than mobility.
(d) is incorrect because cleft lip does not primarily affect GI function. Ranitidine is not routinely given to infants with cleft lip unless reflux is present.
Question 12.
The nurse in the recovery room is caring for a 5-year-old boy who just underwent tonsillectomy. When observing the boy, which of the following would the nurse report to the surgeon immediately?
(a) Vomiting episode
(b) Blood trickling down the throat
(c) Dark brown blood on teeth
(d) Complains of sore throat
Answer:
(b) Blood trickling down the throat
Explanation:
Tonsillectomy is an outpatient procedure performed to remove the tonsils due to recurrent tonsillitis, airway obstruction, or debris (tonsil stones). Blood trickling down the throat indicates bleeding is occurring from the surgical site and warrants immediate notification of the surgeon.
Rationale:
(a) is incorrect because vomiting commonly occurs after surgery and does not need to be reported. The nurse should be prepared to administer antiemetics, keep the patient NPO, and position the patient to prevent aspiration of vomitus.
(c) is incorrect because dark brown blood on the teeth is “old blood” and does not need to be reported. Bright red blood is an indication of current bleeding, which is the priority concern.
(d) is incorrect because a sore throat is expected after tonsillectomy and does not need to be reported to the healthcare provider.
Question 13.
The nurse is assessing a 5-month-old infant girl with oral candidiasis. Which of the following related conditions does the nurse assess the infant for?
(a) Aphthous ulcers
(b) Herpes simplex infection
(c) Diaper rash
(d) Eczema
Answer:
(c) Diaper rash
Explanation:
Oral candidiasis, or thrush, is a yeast or Candida infection in the mouth. The infection can spread through the GI tract to the anus and can also spread as a result of poor hand hygiene performed by the nurse or caregiver. Diaper rash is a common finding with oral candidiasis.
Rationale:
(a) is incorrect because aphthous ulcers (commonly called canker sores) are not related to oral candidiasis. Often, the cause of aphthous ulcers is unknown. They last 10 to 14 days, usually heal without the need for medication, and don’t commonly leave a scar.
(b) is incorrect because herpes simplex infection is caused by the herpes simplex virus and is not related to oral candidiasis.
(d) is incorrect because eczema is a group of skin conditions (skin becomes inflamed and irritated) that are not related to oral candidiasis.
Question 14.
A 4-year-old boy who has experienced frequent ear infections is diagnosed as having mixed hearing loss. Which of the following complications does the clinic nurse assess the boy for?
(a) Recurring temporal headaches
(b) Mandible inflammation
(c) Delayed language development
(d) Serosanguineous ear drainage
Answer:
(c) Delayed language development
Explanation:
Mixed hearing loss is due to damage to both the inner ear and the middle or outer ear, and is a combination of sensorineural as well as conductive hearing loss. Children who experience hearing loss, regardless of the cause, are at increased risk for delayed language development. Children learn to speak by listening and replicating sounds, and if hearing is damaged, then speech cannot be replicated.
Rationale:
(a) is incorrect because recurring temporal headaches are unrelated to mixed hearing loss. Muscle injury, inflammation, or viral infection are more commonly the cause of recurring temporal headaches.
(b) is incorrect because mandible inflammation is unrelated to mixed hearing loss.
(d) is incorrect because sero-sanguineous ear drainage is due to infection or trauma to the inner or middle ear.
Question 15.
The nurse in the emergency room has just admitted a 4-year-old boy whose temperature is 104°F (40°C) and has inspiratory stridor, restlessness, and is leaning forward and drooling. What is the nurse’s priority?
(a) Auscultate lungs and place the boy in a C02 mist tent
(b) Encourage PO fluids and reduce anxiety
(c) Examine the boy’s throat and perform throat culture
(d) Notify the healthcare provider immediately and prepare for intubation
Answer:
(d) Notify the healthcare provider immediately and prepare for intubation
Explanation:
This child has classic signs of acute epiglottitis, or inflammation of the epiglottis. This is an airway emergency in pediatric patients. The nurse must notify the healthcare provider immediately and prepare for intubation.
Rationale:
(a) is incorrect because the nurse already knows the boy is experiencing inspiratory stridor and exhibiting signs of respiratory distress. A CO2 mist tent will not help relieve epiglottitis. The boy needs humidified oxygen and potentially intubation.
(b) is incorrect because PO fluids are not safe for a patient in respiratory distress. IV fluids should be administered. Anxiety reduction is important, but this is a psychosocial need, and airway is the priority physical need.
(c) is incorrect because examining the throat may cause laryngospasm which can potentially be fatal. Further assessment is not needed at this time. The nurse must intervene to provide respiratory support.
Question 16.
A 3-year-old girl has been diagnosed with strabismus. Which of the following signs does the nurse assess as manifestations of strabismus? (Select all that apply.)
(a) Closing one eye to see
(b) Excessive rubbing of eyes
(c) Tilting the head to one side to see
(d) Squinting to focus
(e) Sitting close to the TV
(f) Difficulty doing close-up work
Answer:
(a) Closing one eye to see
(c) Tilting the head to one side to see
(d) Squinting to focus
Explanation:
Strabismus (also known as “cross-eyed”) is misalignment of the eyes due to either cranial nerve weakness, neuromuscular eye movement difficulty, or imbalance of extraocular muscles. The child with strabismus will close one eye, tilt the head to the side, or squint in order to focus.
Rationale:
(b) is incorrect because excessive rubbing of the eyes is a manifestation of myopia (nearsightedness).
(e) is incorrect because sitting close to the TV is a manifestation of myopia.
(f) is incorrect because difficulty doing close-up work is a manifestation of hyperopia (farsightedness).
Question 17.
The nurse in the clinic is caring for a 9-year-old boy complaining of eye pain who was brought in by his parents. Which of the following symptoms would alert the nurse to a corneal abrasion? (Select all that apply.)
(a) Bloodshot eye
(b) Increased tears
(c) Unaffected vision
(d) Ability to see well in bright light
(e) Blurry vision
Answer:
(a) Bloodshot eye
(b) Increased tears
(e) Blurry vision
Explanation:
Corneal abrasions can occur with foreign bodies (dust, lint, sand) or when there is trauma to the cornea from a scratch or brushing against the eye. Symptoms of corneal abrasions include pain, stinging or burning, blurry vision, bloodshot eyes, swollen eyelids, increased tears, and foreign body sensation.
Topical anesthetic or steroid eye drops can cause corneal abrasions as an adverse effect, so the eye should be patched when these drugs are being used. Corneal abrasion can also result from Bell’s Palsy, so artificial tears should be used to keep the eye lubricated on the affected side.
Rationale:
(c) is incorrect because corneal abrasions usually affect vision temporarily and heal within a day or two.
(d) is incorrect because corneal abrasions often cause photosensitivity.
Question 18.
The parents of a 9-year-old girl diagnosed with amblyopia are learning about treatment options from the nurse. Which of the following treatments does the nurse inform the parents of? (Select all that apply.)
(a) Glasses
(b) Eye patch on the strong eye for 6 to 10 hours daily
(c) Atropine drops in the weak eye
(d) Surgery
(e) Corticosteroid drops
Answer:
(a) Glasses
(d) Surgery
Explanation:
Amblyopia (also known as “lazy eye”) is misalignment of the eyes due to miscommunication between the eyes and the brain, most commonly caused by strabismus. The affected eye appears normal upon inspection, but vision is decreased. Treatment for strabismus includes glasses, eye patch over the strong eye, atropine drops in the strong eye, and corrective surgery.
Rationale:
(b) is incorrect because eye patching should only be used part-time, 4 to 6 hours daily to prevent reverse amblyopia from developing on the stronger eye.
(c) is incorrect because atropine drops are placed in the stronger eye as a treatment for amblyopia. (The atropine dilates the pupil of the stronger eye, making it difficult to see near, and forcing the weaker eye to strengthen.)
(e) is incorrect because corticosteroid drops are not commonly used to treat amblyopia. Ophthalmic corticosteroid medications are used to treat inflammation of the eye after ophthalmic surgery or other eye inflammation related to infections or damage to the eye from a chemical or foreign body.
Question 19.
The preoperative nurse is teaching the parents of a 3-year-old boy who is scheduled for bilateral myringotomy. Which of the following statements does the nurse include in the teaching? (Select all that apply.)
(a) “The procedure is performed under general anesthesia.”
(b) “The surgeon will make a hole in the eardrum through which a small tube will be placed.”
(c) “Your son will need to stay overnight after the procedure.”
(d) “You will need to bring your son back in 7 to 10 days to have the sutures removed.”
(e) “The tubes will likely stay in place for 6 to 18 months.”
Answer:
(a) “The procedure is performed under general anesthesia.”
(b) “The surgeon will make a hole in the eardrum through which a small tube will be placed.”
(e) “The tubes will likely stay in place for 6 to 18 months.”
Explanation:
Bilateral myringotomy is an incision into the tympanic membrane, performed to relieve fluid collection from the middle ear, resulting in relief of pressure and drainage of purulent fluid. Small tubes are placed in holes created during surgery under general anesthesia, and the tubes fall out on their own after 6 to 18 months of being in place but must be surgically removed if the tubes remain in place longer than 2 years.
Rationale:
(c) is incorrect because this is generally an outpatient surgical procedure unless the child has significant medical history.
(d) is incorrect because no sutures are placed during a bilateral myringotomy.
Question 20.
The nurse in the family practice office is speaking with the parents of a 7- year-old girl diagnosed with frequent, recurring strep throat. Which of the following statements by the parents indicate the parents understand the tonsillectomy procedure?
(a) “Our daughter will be given general anesthesia for the procedure.”
(b) “We will need to change her dressings the day after surgery.”
(c) “We will need to watch her for bleeding.”
(d) “She may not want to eat solid foods for about a week.”
(e) “We will bring her back in a week to have the stitches taken out.”
Answer:
(a) “Our daughter will be given general anesthesia for the procedure.”
(c) “We will need to watch her for bleeding.”
(d) “She may not want to eat solid foods for about a week.”
Explanation:
Tonsillectomy is an outpatient procedure performed to remove the tonsils, due to recurrent infection (tonsillitis), airway obstruction, or debris (tonsil stones). The procedure is performed under general anesthesia and takes approximately 20 minutes to perform.
There is a risk for bleeding, which generally occurs the same day of surgeiy or in 7 to 10 days when the scabs come off. The throat is extremely sore for about a week after the surgery, and children usually do not eat solid foods during this time.
Rationale:
(b) is incorrect because the procedure is performed through the mouth and no dressing changes are required.
(e) is incorrect because no sutures are used in a tonsillectomy procedure.
Question 21.
The parents of a 9-month-old girl have brought her in to the clinic for acute otitis media. Which of the following manifestations does the nurse expect to find? (Select all that apply.)
(a) Pulling at the ear
(b) Irritability
(c) Hearty appetite
(d) Smiling and cooing
(e) Malaise
(f) Low temperature
Answer:
(a) Pulling at the ear
(b) Irritability
(e) Malaise
Explanation:
Otitis media occurs when the eustachian tube is blocked due to nasal allergy attack or upper respiratory infection, causing fluid collection in the middle ear. Symptoms in infants and children include ear pain, pulling at the ear, irritability, rapid onset, malaise, and poor feeding.
Rationale:
(c) is incorrect because the nurse will expect the infant with otitis media to have a poor appetite, pain while bottle-feeding or breastfeeding, and decreased nutritional intake.
(d) is incorrect because the nurse will expect the infant with otitis media to be irritable.
(f) is incorrect because the nurse will expect to see an elevated temperature in an infant with otitis media.
Question 22.
A 7-year-old boy is in the clinic with his parents to see the nurse. The parents tell the nurse they believe he has trouble seeing. Which of the following sign
(a) Imitation of facial expressions
(b) Frequent blinking
(c) Squinting
(d) Holding objects close
(e) Appropriate eye contact
(f) Tilting the head to the side to hear when someone whispers
Answer:
(b) Frequent blinking
(c) Squinting
(d) Holding objects close
Explanation:
Vision impairment can be due to several different factors, including amblyopia or strabismus, nearsightedness, sensory impairment, or corneal abrasion. Children with vision impairment will not be able to track objects, eye contact will be lacking, and they are unable to imitate facial expressions. The nurse will expect to observe the child squinting, holding objects close, and frequent blinking.
Rationale:
(a) is incorrect because the child with vision impairment is often unable to imitate facial expressions.
(e) is incorrect because the child with vision impairment is unable to make eye contact.
(f) is incorrect because this is a symptom of hearing loss, not impaired vision.
Question 23.
The nurse in the school clinic is caring for a 7-year-old girl who comes in for epistaxis. The nurse will initiate which of the following interventions? (Select all that apply.)
(a) Lie the child down on her back on the cot and have her apply pressure to the nostrils
(b) Apply heat to the bridge of the nose
(c) Keep the child calm
(d) Have the child sit upright with her head tilted forward
(e) Administer decongestant medication
(f) Perform nasal suctioning
Answer:
(c) Keep the child calm
(d) Have the child sit upright with her head tilted forward
Explanation:
Epistaxis is a nosebleed and can either be anterior or posterior, depending on where mucosa has been eroded and blood vessels are exposed. Interventions for epistaxis include keeping the child calm, having the child sit upright with their head tilted forward, and applying pressure to both nostrils below nasal bone. The parents should be notified that if interventions do not stop the bleeding, the healthcare provider should be contacted.
Rationale:
(a) is incorrect because when a child is experiencing epistaxis, lying the child down supine may allow blood to run down the nasopharynx and increase risk for aspiration.
(b) is incorrect because heat will cause vasodilation and increase blood flow to the area. An ice pack should be used instead.
(e) is incorrect because decongestant medication is not commonly used to treat epistaxis and may be unsafe for a 7-year-old child.
(f) is incorrect because epistaxis generally does not require nasal suctioning, and this is an inappropriate intervention for a school nurse to perform.
Question 24.
The nursing student in the pediatric clinic is learning about common causes of nasal obstruction in children. The nursing student learns about which of the following? (Select all that apply.)
(a) Foreign body
(b) Deviated septum
(c) Pharyngitis
(d) Rhinitis
(e) Epiglottitis
(f) Accumulation of nasal hairs
Answer:
(a) Foreign body
(b) Deviated septum
(d) Rhinitis
Explanation:
(a), (b), (d) Nasal obstruction can be caused by rhinitis (inflammation of the mucosal lining of the nasal cavity), adenoid hypertrophy, foreign body, deviated septum, nasal polyps, hematoma, or tumors. Children with nasal obstruction are often mouth breathers, as the nasal cavity is blocked preventing breathing through the nose.
Rationale:
(c) is incorrect because pharyngitis is infection of the throat and does not cause nasal obstruction.
(e) is incorrect because epiglottitis is inflammation of the epiglottis and can be an airway emergency but does not cause nasal obstruction.
(f) is incorrect because children do not generally suffer from overgrowth or accumulation of nasal hairs.
Question 25.
A 4-year-old girl in the pediatric emergency room has been diagnosed .with tonsillitis. When assessing the patient, which of the following symptoms does the nurse expect to find? (Select all that apply.)
(a) Deep-red colored tonsils
(b) Sore throat
(c) Blood pressure 70/45
(d) Swollen lymph nodes of the axillae
(e) White or yellow film on tonsils
Answer:
(a) Deep-red colored tonsils
(b) Sore throat
(e) White or yellow film on tonsils
Explanation:
Tonsillitis is infection and inflammation of the tonsils. Symptoms include deep-red tonsils, sore throat, fever, swollen neck lymph nodes, and white or yellow film on the tonsils.
Rationale:
(c) is incorrect because this is hypotensive for a 4-year-old, and tonsillitis does not cause hypotension.
(d) is incorrect because lymph nodes of the neck are swollen in tonsillitis, not the axillae.