# 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 child's tonsils and posterior pharynx. What is the most critical assessment finding the nurse should monitor for in this child with suspected diphtheria?

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## 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 child's tonsils and posterior pharynx. What is the most critical assessment finding the nurse should monitor for in this child with suspected diphtheria?

## 보기

1. Signs of respiratory distress and stridor **✔ 정답**
2. Presence of petechial rash on extremities
3. Complaints of abdominal pain and nausea
4. Changes in urinary output and color

**정답: 1**

## 해설

In diphtheria, the pseudomembrane can cause life-threatening airway obstruction, making monitoring for respiratory distress and stridor the priority. Other options are less critical initial assessments.

## 심화 해설

Understanding the Question

This question focuses on a child presenting with classic signs of diphtheria. The priority for the nurse is to identify the most critical, life-threatening complication to monitor for. The question tests the NCLEX-RN principle of airway prioritization within the "Physiological Integrity" and "Safe and Effective Care Environment" client need categories.

Pathophysiology and Clinical Presentation

Diphtheria is caused by toxigenic strains of Corynebacterium diphtheriae. The hallmark of respiratory diphtheria is the formation of a pseudomembrane, a tough, fibrinous, grayish-white layer composed of dead cells, bacteria, and inflammatory products. This membrane adheres tightly to the mucosa of the tonsils, pharynx, and larynx. The primary, immediate danger is mechanical airway obstruction. As the pseudomembrane expands, it can physically block the upper airway, leading to respiratory distress and stridor, a high-pitched sound indicating a narrowed airway. A case from the United Kingdom highlighted a patient who presented with noisy, laboured breathing and use of accessory muscles due to life-threatening airway obstruction from a diphtheritic pseudomembrane [2].

Analysis of Assessment Options

| Assessment Finding | Pathophysiological Basis | Priority Level |
| --- | --- | --- |
| Signs of respiratory distress and stridor | Direct mechanical obstruction of the upper airway by the expanding pseudomembrane. This is an immediate threat to life [2]. | Highest Priority (Airway) |
| Presence of petechial rash on extremities | Not a typical feature of diphtheria. This is more commonly associated with meningococcemia or other bacterial infections. | Low Priority |
| Complaints of abdominal pain and nausea | Non-specific symptoms that do not represent the most immediate, life-threatening complication of diphtheria. | Low Priority |
| Changes in urinary output and color | Could indicate renal impairment, a late and less common toxin-mediated complication. This does not take precedence over airway management. | Low Priority |

Why Airway is the Critical Focus

The NCLEX-RN exam consistently uses the ABC (Airway, Breathing, Circulation) framework to establish nursing priorities. In diphtheria, the pseudomembrane directly compromises the "A" in the ABCs. While the diphtheria toxin can cause severe systemic complications like myocarditis-induced dilated cardiomyopathy and peripheral neuropathy, as documented in a non-immunized child from Somalia, these are secondary concerns in the acute phase of respiratory distress . The immediate threat is asphyxiation from airway obstruction. Even in a fully immunized child where a breakthrough infection occurs, the presenting symptoms of sore throat and poor oral intake are linked to the pharyngeal disease process, which can rapidly progress to airway compromise . Therefore, vigilant monitoring for signs of respiratory distress and stridor is the most critical nursing assessment to prevent a fatal outcome.References (research sources)

- [2]A Case of Life-Threatening Airway Obstruction Caused by Acute Diphtheria Infection in the United Kingdom.Case reportChu MM, Bennett MR, Harrison A, Cardozo A. (2021) · DOI: 10.7759/cureus.19675

## 임상 시나리오

Diphtheria Airway MonitoringPriority Assessment for Pseudomembrane Obstruction
The primary danger in respiratory diphtheria is mechanical upper airway obstruction from the expanding pseudomembrane. Monitor continuously for stridor, a high-pitched inspiratory sound indicating a narrowed airway.

Assess for signs of increased work of breathing: tachypnea, use of accessory muscles (sternal/suprasternal retractions), and nasal flaring. A change in voice or a brassy cough may signal laryngeal involvement.

CautionDo not attempt to remove the pseudomembrane; it is tightly adhered and manipulation can cause bleeding and worsen obstruction. Prepare for emergency airway management and notify the provider immediately if stridor or distress develops.

## 핵심 개념

- **Pseudomembrane** — A dense, grayish-white layer of necrotic tissue, fibrin, and bacteria that adheres firmly to the mucosa in diphtheria and can cause airway obstruction.
- **Stridor** — A high-pitched, harsh sound heard during inspiration, indicating significant narrowing or obstruction of the upper airway.
- **Diphtheria** — An acute, toxin-mediated infection caused by Corynebacterium diphtheriae, characterized by pseudomembrane formation and potential for airway obstruction and cardiac toxicity.
- **ABCs (Airway, Breathing, Circulation)** — The fundamental priority sequence in nursing assessment and intervention, where airway patency is always the first and most critical concern.

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