PEDIATRIC NURSING REVIEW QUESTIONS

PEDIATRIC RESPIRATORY INFECTIOUS EMERGENCIES Authors: Scott DeBoer, RN, MSN, CEN, CPEN, CCRN, CFRN, EMT-P, and Michael Seaver, RN, BA, Dyer, In, Vernon Hills, IL Section Editors: Scott DeBoer, RN, MSN, CEN, CPEN, CCRN, CFRN, EMT-P, and Michael Seaver, RN, BA

he review questions that are featured in each of the issues of the JEN are based upon the Emergency Nursing Core Curriculum and other pertinent resources to emergency nursing practice, pediatric and adult. These questions offer emergency nurses an opportunity to test their knowledge about their practice. These questions appear both in print and online.

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REFERENCES 1. Chen SC, Chen KL, Chen KH, Chien ST, Chen KT. Updated diagnosis and treatment of childhood tuberculosis. World J Pediatr. 2013;9(1):9-16. 2. DeBoer S. Certified Pediatric Emergency Nurse Review: Putting It All Together. 2nd ed. Dyer, IN: Peds-R-Us Medical Education; 2011. 3. Committee on Infectious Diseases, American Academy of Pediatrics. Recommendations for prevention and control of influenza in children, 2012-2013. Pediatrics. 2012;130(4):780-92. 4. Duman M, Gencpnar P, Ozbek O, Ozdemir D, Sayner A. Value of rapid antigen test for pandemic influenza A (H1N1) 2009 in the pediatric emergency department. Pediatr Emerg Care. 2013;29(5):612-6. 5. García-García M, Calvo C, Pozo F, Villadangos P, Perez-Brena P, Casas I. Spectrum of respiratory viruses in children with community-acquired pneumonia. Pediatr Infect Dis J. 2012;31(8):808-13.

QUESTIONS 1. A 4-year-old child presents to the emergency department with

a cough, fever of 101.0°F (38.3°C), swollen glands, decreased appetite/activity, weight loss, and night sweats. The mother tells you the child has had a periodic cough and fever for several weeks that have worsened over the past week. The child appears small for his age. The triage nurse should have a high index of suspicion for what disease? A. Croup B. Flu C. Meningitis D. Tuberculosis (TB) 2. A 3-year-old child diagnosed with H1N1 (“swine flu”) is being

discharged from the emergency department. Which statement by the caregiver demonstrates a correct understanding of the discharge instructions? A. “I will give her 325 mg of aspirin every 4 hours for fever.” B. “I will bring her back to the emergency department if her fever lasts more than 5 days or her breathing worsens.” C. “I will follow up with our pediatrician in 2 weeks.” D. “It’s OK to have her return to daycare tomorrow.” 3. A 6-year-old child presents to the emergency department with

the complaint of a persistent fever. His mother states that he was just diagnosed with H1N1 (swine flu) 2 days ago. The child is awake, alert, and in no distress. What would the priority intervention be at this time? A. Administer antipyretics for fever. B. Place the child in a private room. C. Place an isolation mask on the child. D. Obtain an accurate weight in kilograms. Scott DeBoer is Flight Nurse, University of Chicago Hospitals, Chicago, IL, and Founder, Peds-R-Us Medical Education, Dyer, IN. Michael Seaver is Senior Healthcare Consultant, Vernon Hills, IL. Review questions and answers on topics about which nurses should be knowledgeable. J Emerg Nurs 2014;40:e103-e104. 0099-1767 Copyright © 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.

4. Cultures for respiratory syncytial virus (RSV), influenza (flu),

and pertussis (whooping cough) should be obtained using a swab inserted into the A. Posterior nasopharynx B. Posterior oropharynx C. Anterior nasopharynx D. Anterior oropharynx

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5. In the continental United States, RSV is most common during

which season? A. Spring B. Summer C. Autumn D. Winter

ANSWERS 1. Correct answer: D This presentation virtually screams “possible TB”! Mycobacterium TB is spread through airborne particles when an infected person sneezes, coughs, speaks, sings, yodels, or raps. TB droplets can remain suspended in the air for several hours, so close-quarters contact, such as in hospitals or homes, allows for the relatively easy spread of TB. Fortunately, TB is not generally transmitted through environmental surfaces (bedside tables, linens, and so on) or personal items (hairbrushes and so on). Interestingly, most young children with TB are either minimally infectious or not infectious because the TB bacteria are confined to the small air spaces. As the TB patient ages, the “tubercles” of bacteria grow around and rupture into the larger airways, making the bacteria much easier to expel. Latent TB infection occurs when a person has a positive TB skin test but has no symptoms of active TB and is not infectious. If the disease is going to develop into active TB, it will usually do so within the first 2 years after infection. Once the latent infection progresses to active disease, the classic symptoms, such as night sweats, weight loss (formerly called “consumption”), and blood-tinged sputum, are present. Common initial treatment for TB includes INH (isoniazid) and rifampin; however, with the advent of multidrug-resistant TB (MDR-TB), which is resistant to INH/rifampin, and—more recently—extensively drug-resistant TB (XDR-TB), which is resistant to INH, rifampin, and fluoroquinolones (Cipro, ciprofloxacin), treatment regimens have become more of a challenge. Of note, in 2009, the Centers for Disease Control and Prevention reported that the average cost of hospitalization for 1 patient with XDR-TB was an astonishing $483,000! ED staff should have a high index of suspicion for possible TB cases and place patients in isolation with doors remaining closed until the absence of TB has been confirmed. In addition, staff in close contact with these patients must wear N95 masks to minimize the chance of becoming infected. Chen et al, 1 9-16; DeBoer, 2 206. 2. Correct answer: B Worsening respiratory symptoms may signal that the child has pneumonia and should be considered a “red flag.” Bacterial

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pneumonia is a very real complication of H1N1 and should be treated without delay. Generally speaking, follow-up should occur in a week or sooner, especially if the child remains febrile, has new symptoms, or looks and/or acts sicker. Aspirin is no longer recommended to treat fever in children because of its association with Reye syndrome. The daycare facility is most likely where this child acquired H1N1, so returning to the “scene of the crime” this early would definitely not benefit this child or the other children and staff. One should remember that viral shedding continues for 5 to 10 days from the onset of symptoms and even longer in young children. Children with proven or strongly suspected influenza should generally be kept out of daycare/school for 1 to 2 weeks. DeBoer, 2 209; Committee on Infectious Diseases, American Academy of Pediatrics, 3 780-792.

3. Correct answer: C Safety questions can take many forms, and this is one of them. On the basis of the given presentation, it is obvious that this child is a “nonurgent,” or stable, patient. Considering that one really does not want an emergency department full of people exposed to H1N1, placing an isolation mask on the child will help to protect other patients, families, or staff members from potential infection. Even though all of the listed interventions are appropriate, the first priority here is safety. DeBoer, 2 210; Committee on Infectious Diseases, American Academy of Pediatrics, 3 780-792; Duman et al, 4 612-616.

4. Correct answer: A For icky/contagious things such as RSV, flu, and pertussis in children, the posterior nasopharynx is the site of choice to obtain cultures. The anterior nasopharynx (front of the nose), anterior oropharynx (front of the mouth), and posterior oropharynx (back of the mouth) may yield positive results but are less likely to do so. Down the nose is where the swab goes! DeBoer, 2 211; Committee on Infectious Diseases, American Academy of Pediatrics, 3 780-792; Duman et al, 4 612-616.

5. Correct answer: D RSV “season,” depending on where one lives in the country, is most commonly from the late autumn until early spring. Although patients can still acquire RSV during the summer, in most cases, summer is generally when we have time to recover from and prepare for the next RSV season. RSV is often seen not only in “ex-preemies” but also in term babies whose siblings are playing with all the other supposedly healthy children in daycare. DeBoer, 2 179; García-García et al, 5 808-813.

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