# 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? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542264 > language: ko > subject: Child Health ## 문제 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? ## 보기 1. Temperature of 101.2°F (38.4°C) with chills 2. Cervical lymphadenopathy with tender, swollen nodes 3. Inspiratory stridor with suprasternal retractions **✔ 정답** 4. Thick, purulent nasal discharge with epistaxis **정답: 3** ## 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. ## 심화 해설 Clinical Presentation and Pathophysiology The scenario describes a 6-year-old child with a sore throat, low-grade fever, and a grayish-white membrane covering the posterior pharynx and tonsils. This classic presentation is highly suggestive of respiratory diphtheria, caused by toxigenic strains of Corynebacterium diphtheriae. The bacterium produces a potent exotoxin that causes local tissue necrosis, leading to the formation of a dense, adherent pseudomembrane composed of fibrin, dead epithelial cells, leukocytes, and bacteria [2,3]. This membrane can extend from the tonsils into the pharynx, larynx, and trachea, creating a mechanical obstruction that compromises the airway. Analysis of Assessment Findings When prioritizing care for a child with suspected diphtheria, the nurse must apply the airway, breathing, and circulation (ABC) framework. The most immediate threat to life is airway compromise due to the expanding pseudomembrane. - Option 1: A temperature of 101.2°F (38.4°C) with chills reflects the systemic inflammatory response to the infection. While fever requires monitoring and antipyretic intervention, it does not represent an immediate threat to the airway or hemodynamic stability in the same way a mechanical obstruction does. - Option 2: Cervical lymphadenopathy with tender, swollen nodes is a common finding in diphtheria. Extensive lymphadenopathy and soft tissue edema can create a "bull neck" appearance, which is a sign of severe disease [2,4]. While this finding is concerning and indicates toxin-mediated damage, it is a progression marker rather than an immediate airway emergency requiring instantaneous intervention. - Option 3: Inspiratory stridor with suprasternal retractions is a critical finding. Inspiratory stridor is a high-pitched sound generated by turbulent airflow through a narrowed upper airway, specifically at the level of the larynx or trachea. Suprasternal retractions indicate the use of accessory muscles to overcome significant airway resistance. Together, these signs confirm that the pseudomembrane has extended into the larynx, causing a life-threatening obstruction [1,4]. This represents an immediate failure of the "A" in the ABCs and requires emergent intervention, such as securing the airway and administering diphtheria antitoxin. - Option 4: Thick, purulent nasal discharge with epistaxis can occur with nasal diphtheria, which may accompany the pharyngeal form. While indicative of mucosal infection and necrosis, this finding does not signal an immediate threat to airway patency. Clinical Priority and Intervention The presence of inspiratory stridor and retractions is the most concerning assessment finding because it signals impending respiratory failure from a mechanical blockage. In diphtheria, the pseudomembrane is firmly adherent; forceful removal attempts can cause bleeding and worsen the obstruction. The priority is to maintain a patent airway, which may require endotracheal intubation or a surgical airway if the membrane extends below the glottis. This intervention takes precedence over all others, as respiratory distress from diphtheritic laryngitis can progress rapidly to complete obstruction and death [2,4]. ## 임상 시나리오 Diphtheria Airway ManagementRecognizing Impending Respiratory Failure A child with a grayish-white pharyngeal membrane is at high risk for airway obstruction. The priority assessment is monitoring for signs of upper airway compromise such as inspiratory stridor and suprasternal retractions. Any sign of increased work of breathing necessitates immediate notification of the provider and preparation for emergency airway intervention. Do not attempt to remove the membrane as this can cause bleeding and further obstruction. CautionMaintain a calm environment and allow the child to assume a position of comfort. Avoid agitating the child or performing unnecessary oral examinations, which could dislodge the membrane or trigger complete obstruction. ## 핵심 개념 - **Diphtheria Pseudomembrane** — A dense, adherent grayish-white membrane formed from fibrin, dead tissue, and bacteria in the pharynx, which can cause airway obstruction. - **Inspiratory Stridor** — A high-pitched, harsh sound heard during inspiration, indicating partial obstruction of the upper airway, often at or below the larynx. - **Suprasternal Retractions** — Visible sinking of the soft tissue above the sternum during inspiration, a sign of severe respiratory distress and increased work of breathing. - **ABC Framework** — A prioritization mnemonic (Airway, Breathing, Circulation) used in emergencies to identify and manage the most life-threatening conditions first. ## 같은 주제 문제 - [A 6-year-old child is brought to the emergency department with a 3-day history of sore thr…](https://mymerci.kr/pages/nclex_q.php?qn_id=542265) - [A 4-year-old child is admitted to the pediatric unit with suspected diphtheria. 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