A 6-year-old child is brought to the emergency department with a 3-day history of sore throat, low-grade fever, and difficulty swallowing. The nurse observes a grayish-white membrane covering the posterior pharynx and tonsils. Which assessment finding would be most concerning and require immediate intervention?
1Temperature of 101.2°F (38.4°C) with chills
2Cervical lymphadenopathy with tender, swollen nodes
3Inspiratory stridor with suprasternal retractions✓ 정답
4Thick, purulent nasal discharge with epistaxis
해설
Inspiratory stridor with suprasternal retractions indicates upper airway obstruction, a life-threatening emergency in diphtheria requiring immediate airway management. Other findings like fever or lymphadenopathy are common but less urgent.
Core Nursing ExplanationKey Concept Analysis: This question assesses the nurse's ability to recognize a life-threatening complication of Diphtheria. The grayish-white membrane on the pharynx is the hallmark sign. The most critical complication is Upper airway obstruction caused by the membrane's growth, which can completely block the airway. The question asks for the most concerning finding requiring immediate intervention, testing your skills in Key Point!prioritization and recognizing airway emergencies.
Answer Rationale: Key Point!Inspiratory stridor is a high-pitched, crowing sound heard on inspiration, indicating turbulent airflow through a narrowed airway. Suprasternal retractions (skin pulling in at the base of the neck) are a sign of increased work of breathing and respiratory distress. Together, these findings signal impending airway obstruction, which is the leading cause of death in pharyngeal diphtheria. This requires immediate intervention such as airway suctioning, preparation for intubation or tracheostomy, and administration of Diphtheria antitoxin.
Distractor Analysis:
Watch out for confusion! A fever of 101.2°F (38.4°C) is a common systemic symptom of infection. While it requires monitoring and antipyretics, it is not an immediate, life-threatening concern compared to airway compromise.
Cervical lymphadenopathy ("bull neck") is a classic finding in severe diphtheria due to lymph node swelling. It indicates significant infection but, by itself, does not constitute an emergency requiring the same level of urgency as airway obstruction.
CORRECT. Inspiratory stridor with retractions is the definitive sign of critical airway narrowing, demanding immediate action to secure the airway and prevent respiratory arrest.
Purulent nasal discharge and epistaxis (nosebleed) can occur, especially in nasal diphtheria. These are localized symptoms that, while requiring care, are not immediately life-threatening.
Related Concepts: This scenario highlights the ABC (Airway, Breathing, Circulation) priority framework. Airway always comes first. Diphtheria is prevented by the DTaP/Tdap vaccine. The toxin produced by Corynebacterium diphtheriae can cause myocarditis and neuritis, but airway obstruction is the most acute threat.
Concept Summary
Concept
Key Points
Diphtheria
Bacterial infection causing a pseudomembrane in the throat/nose. Toxin can damage heart/nerves.
High, but often allows time for medication (bronchodilators).
Snoring (Stertor)
Partial obstruction in nose or pharynx (e.g., enlarged tonsils, tongue falling back).
Low to Moderate (requires monitoring).
Anatomy, Physiology & Pharmacology Points
Pathophysiology: The bacteria release a potent exotoxin. This toxin kills mucosal cells, forming a gray, adherent pseudomembrane composed of dead cells, fibrin, and bacteria. This membrane can detach and cause sudden airway obstruction.
Pharmacology:Diphtheria antitoxin is a horse serum-derived antibody that neutralizes circulating toxin. It must be given early, before toxin binds to tissues. A skin test for horse serum allergy is required prior to administration.
Memory Tips
Mnemonic for Diphtheria Complications:Airway, Bull neck, Carditis, Diplopia (from neuritis). A is first and foremost!
Stridor Sound: Think of a tight, high-pitched "CROWING" sound on INspiration. It's the sound of air struggling to get IN.
High-Frequency NCLEX Topics
This integrates several high-yield NCLEX areas: pediatric emergencies, infection control and communicable diseases (isolation for droplet precautions!), vaccine-preventable illnesses, and above all, prioritization (ABCs) and recognition of respiratory distress.
Watch Out for Question Variations!
Symptom Identification → Priority Action: "The nurse observes inspiratory stridor in a child with diphtheria. What is the priority nursing action?" (Answer: Ensure a patent airway; prepare for emergency intubation/suction).
Isolation Precautions: "What type of isolation precautions are required for this child?" (Answer: Droplet precautions in addition to standard precautions).
Medication Focus: "The provider orders diphtheria antitoxin. Which nursing action is essential prior to administration?" (Answer: Perform a skin test for sensitivity to horse serum).
Nursing Clinical Practice GuideClinical Scenario: You are the triage nurse in a busy Pediatric ED. A frantic mother brings in her 6-year-old son, who is leaning forward, drooling slightly, and making a harsh noise with each breath. You see the classic "bull neck" appearance and, upon a quick look with a penlight, spot a grayish membrane at the back of his throat.
Nursing Intervention Strategy:
Immediate Assessment & Action (ABCs):
Airway: Do NOT attempt to visualize the throat with a tongue depressor if stridor is present—this can trigger complete laryngospasm and obstruction. Call for the emergency/crash cart and respiratory therapist immediately.
Breathing: Assess oxygen saturation via pulse oximetry. Administer humidified oxygen via the least invasive method tolerated (e.g., blow-by). Continuously monitor for worsening retractions or cyanosis.
Circulation: Obtain IV access for emergency medications and fluids.
Infection Control: Place the child in a negative pressure isolation room if available. Don appropriate PPE for Droplet Precautions (mask, gown, gloves, eye protection) before any close contact.
Collaborative Care:
Alert the physician, anesthesiologist, and ENT specialist STAT for potential emergency airway management (intubation or tracheostomy).
Prepare for administration of diphtheria antitoxin as soon as it is ordered, ensuring allergy screening is done.
Administer antibiotics (e.g., erythromycin) as ordered to eliminate the bacteria.
Monitoring & Support: Continuously monitor vital signs, cardiac rhythm (toxin can cause myocarditis), and neurological status. Provide calm reassurance to the child and family.
Patient Safety and Precautions:
Airway Triggers: Avoid agitating the child. Keep procedures to a minimum. Do not leave the child unattended.
Antitoxin Administration: Be prepared for anaphylaxis. Have epinephrine and emergency equipment at the bedside during and after administration.
Isolation: Maintain droplet precautions until after 48 hours of effective antibiotic therapy and until two consecutive negative cultures are obtained.
Nursing Procedure & Medication FlowManaging a Potential Airway Emergency:
Stay with the patient. Call for help using the emergency call system.
Position: Allow the child to assume a position of comfort, often sitting up and leaning forward (tripod position).
Prepare: Ensure the suction is turned on and a Yankauer suction tip is ready. Have an emergency tracheostomy tray at the bedside.
Medication Prep: If ordered, have racemic epinephrine (for nebulization to reduce mucosal edema) and IV corticosteroids ready.
Document: Precisely document the onset and characteristics of stridor, retractions, and the patient's level of consciousness.
A Word from Your Senior Nurse
"In the ED, seconds count. A child with stridor is a 'don't you dare leave this room' kind of patient. Your eyes and ears are your best assessment tools—trust them. That crowing sound means the airway is already dangerously narrow. Your calm, swift action to mobilize the team and secure the airway can be the difference between a good outcome and a tragedy. Remember, in pediatrics, they decompensate quickly but can also bounce back amazingly fast with the right intervention. This is where your foundational knowledge of pathophysiology and prioritization becomes real, life-saving skill."
Diphtheria — A serious bacterial infection caused by Corynebacterium diphtheriae, characterized by the formation of a gray pseudomembrane in the throat/nose and the release of a potent exotoxin affecting the heart and nerves.
Inspiratory Stridor — A high-pitched, crowing sound heard during inspiration, indicating turbulent airflow through a partially obstructed upper airway (larynx or trachea). A medical emergency.
Suprasternal Retractions — Visible sinking in of the soft tissues of the neck just above the sternum during inspiration, a sign of increased work of breathing and respiratory distress.
Pseudomembrane — A thick, grayish-white, adherent layer composed of dead cells, fibrin, inflammatory cells, and bacteria. In diphtheria, it forms on the tonsils, pharynx, and/or nasal cavity and can cause airway obstruction.
Diphtheria Antitoxin — A medication containing antibodies that neutralize the circulating diphtheria toxin. It is a critical component of treatment and must be administered as early as possible. Derived from horse serum, requiring a prior skin test for allergy.