The nurse employed in an emergency department is monitoring a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. The nurse interprets this finding as indicating:
1. Extreme fatigue
2. The presence of pain
3. An airway obstruction
4. The presence of dehydration
3
Rationale: Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward supported by arms, chin thrust out, mouth open), nasal flaring, tachycardia, a high fever, and sore throat. "Extreme fatigue," "the presence of pain," and "the presence of de-hydration" are inaccurate interpretations.
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