A nurse is caring for a 6-year-old client with tonsillitis. Which further assessment finding requires immediate intervention?

Question

Quizplus · Accepted Answer

11ecbb05_cadc_c86b_b433_1356de762f89_MD0009_00 Trismus (inability to open the mouth due to a tonic contraction of the muscles used for chewing) may indicate a more serious complication of tonsillitis, a peritonsillar or retropharyngeal abscess (collection of pus). Other features include a "hot potato" or muffled voice, pooling of saliva, and deviation of the uvula to one side. This abscess can occlude the airway, making it a medical emergency. Surgical intervention (tonsillectomy or incision and drainage) is often required. In the meantime, maintaining an adequate airway is essential. (Option A) Dry mucous membranes indicate dehydration. This is to be expected in a child with tonsillitis due to the refusal to swallow. Hydration with IV fluids may be indicated in severe cases. Dehydration requires intervention but is not the priority. (Option C) Pulling at the ears is a common symptom in children with otitis media. An ear infection frequently accompanies tonsillitis in children and is easily treated with antibiotics. This is not a serious finding. (Option D) The most common bacterial cause of tonsillitis is group A streptococcal infection. The same organism can also result in scarlet fever, which manifests as fine sandpaper-like skin rash and fever. Antibiotics will effectively treat this condition, and it is not life-threatening. Educational objective: Peritonsillar or retropharyngeal abscess is a serious complication that can result from tonsillitis or pharyngitis. A "hot potato" or muffled voice, trismus (inability to open the mouth), pooling of saliva, and deviation of the uvula to one side are the presenting features. Maintaining an adequate airway is essential.

A Nurse Is Caring for a 6-Year-Old Client with Tonsillitis