NR 328 EDAPT TONSILLITIS CASE STUDY|2025 UPDATE|100% CORRECT
Tonsillitis Case Study
The nurse is caring for a 5-year-old child with tonsillitis with retropharyngeal cellulitis.
Review client information in the electronic health record (EHR) before answering each
question.
Recognizing Cues
4/5/20XX
07:00
A 5-year-old child was admitted yesterday from the emergency department (ED) with a
1-day history of fever, sore throat for 3 days, and swelling in the right neck. The child's
diagnosis is tonsillitis with retropharyngeal cellulitis. The child was admitted to the
hospital concerning possible airway compromise. The caregiver reports a history of
increasing difficulty eating and denies trauma to the neck. The child is very
uncomfortable and has been medicated with intravenous (IV) morphine 3 mg several
times during the night for pain in the throat and neck, last time 3 hours ago. Assessment
includes respiratory WNL, bowel sounds are present all 4 quads, IV 24 g right forearm
infusing D5 1/2 with KCl 20 mEq/L at 49 ml/hr. IV site without redness or edema. Today’s
weight is 14.9kg, which is down from 15.2kg upon admission weight yesterday. CT
ordered for this morning.
Select the 4 findings that require immediate attention.
The following items need immediate follow-up by the nurse:
• Admitted due to compromised airway secondary to tonsillitis and retropharyngeal
cellulitis. Also, a patent airway must be maintained (think ABCs).
• History of increasing difficulty eating probably due to throat discomfort.
• Continues to have significant discomfort requiring medication with morphine
several times during the night signifies the pain is not controlled.
• Weight down from admission is mostly likely due to the child being in pain and
refusing to eat. This needs to be monitored so that the child does not continue to
lose weight.
The nothing by mouth (NPO) status is appropriate given the pending computerized
tomography (CT) scan that is scheduled for this morning. The intravenous (IV) site is
without redness or edema and is infusing IV fluids without issue. These are normal
findings that do not require immediate attention.
Analyzing Cues
4/5/20XX
07:00
A 5-year-old child was admitted yesterday from the emergency department (ED) with a
1-day history of fever, sore throat for 3 days, and swelling in the right neck. The child's
diagnosis is tonsillitis with retropharyngeal cellulitis. The child was admitted to the
hospital concerning possible airway compromise. The caregiver reports a history of
increasing difficulty eating and denies trauma to the neck. The child is very
uncomfortable and has been medicated with intravenous (IV) morphine 3 mg several
times during the night for pain in the throat and neck, last time 3 hours ago. Assessment
includes respiratory WNL, bowel sounds are present all 4 quads, IV 24 g right forearm
, infusing D5 1/2 with KCl 20 mEq/L at 49 ml/hr. IV site without redness or edema. Today’s
weight is 14.9kg, which is down from 15.2kg upon admission weight yesterday. CT
ordered for this morning.
4/5/20XX
07:30
Initial physical assessment reveals:
CV: WNL+ 2 pulses in all extremities. Capillary refill < 3 seconds.
Resp: Breath sounds clear on room air all lobes, no retractions or upper airway noise,
good aeration.
GI: bowel sounds present all quadrants, nasogastric tube secured to R naris.
Integ: Pink and intact except for intravenous (IV) 24 g right forearm infusing D5 1/2 with
KCl 20 mEq/L at 49 ml/hr., site w/o redness or edema; puncture wounds from lab draws.
ENT: mucous membranes moist and intact. Pain FACES 3/5 neck and throat. PEWS 1.
VS: BP 124/70, T 37 (98.6 F), P 95, RR 24 , O2 sat 100%
For each client finding below, click to specify if the finding is consistent with
the disease process of tonsillitis, pneumonia, or epiglottitis. Each finding may
support more than one disease process. Note: Each column must have at least
one response option selected.
Common clinical manifestations include:
• tonsillitis
• red, swollen tonsils
• white or yellow patches on the tonsils
• sore throat
• difficulty or painful swallowing
• enlarged tender glands (lymph nodes) in the neck
• scratchy, muffled, or throaty voice
• neck pain or stiff neck
• headache
• fever may or may not occur
• pneumonia
• cough with yellow or green sputum
• fever
• sweating
• chills
• shortness of breath
• wheezing or adventitious breath sounds
• rapid, shallow breathing
• sharp or stabbing chest pain that gets worse when deep breathing or coughing
• loss of appetite
• low energy
• fatigue
• nausea and vomiting especially in small children
Tonsillitis Case Study
The nurse is caring for a 5-year-old child with tonsillitis with retropharyngeal cellulitis.
Review client information in the electronic health record (EHR) before answering each
question.
Recognizing Cues
4/5/20XX
07:00
A 5-year-old child was admitted yesterday from the emergency department (ED) with a
1-day history of fever, sore throat for 3 days, and swelling in the right neck. The child's
diagnosis is tonsillitis with retropharyngeal cellulitis. The child was admitted to the
hospital concerning possible airway compromise. The caregiver reports a history of
increasing difficulty eating and denies trauma to the neck. The child is very
uncomfortable and has been medicated with intravenous (IV) morphine 3 mg several
times during the night for pain in the throat and neck, last time 3 hours ago. Assessment
includes respiratory WNL, bowel sounds are present all 4 quads, IV 24 g right forearm
infusing D5 1/2 with KCl 20 mEq/L at 49 ml/hr. IV site without redness or edema. Today’s
weight is 14.9kg, which is down from 15.2kg upon admission weight yesterday. CT
ordered for this morning.
Select the 4 findings that require immediate attention.
The following items need immediate follow-up by the nurse:
• Admitted due to compromised airway secondary to tonsillitis and retropharyngeal
cellulitis. Also, a patent airway must be maintained (think ABCs).
• History of increasing difficulty eating probably due to throat discomfort.
• Continues to have significant discomfort requiring medication with morphine
several times during the night signifies the pain is not controlled.
• Weight down from admission is mostly likely due to the child being in pain and
refusing to eat. This needs to be monitored so that the child does not continue to
lose weight.
The nothing by mouth (NPO) status is appropriate given the pending computerized
tomography (CT) scan that is scheduled for this morning. The intravenous (IV) site is
without redness or edema and is infusing IV fluids without issue. These are normal
findings that do not require immediate attention.
Analyzing Cues
4/5/20XX
07:00
A 5-year-old child was admitted yesterday from the emergency department (ED) with a
1-day history of fever, sore throat for 3 days, and swelling in the right neck. The child's
diagnosis is tonsillitis with retropharyngeal cellulitis. The child was admitted to the
hospital concerning possible airway compromise. The caregiver reports a history of
increasing difficulty eating and denies trauma to the neck. The child is very
uncomfortable and has been medicated with intravenous (IV) morphine 3 mg several
times during the night for pain in the throat and neck, last time 3 hours ago. Assessment
includes respiratory WNL, bowel sounds are present all 4 quads, IV 24 g right forearm
, infusing D5 1/2 with KCl 20 mEq/L at 49 ml/hr. IV site without redness or edema. Today’s
weight is 14.9kg, which is down from 15.2kg upon admission weight yesterday. CT
ordered for this morning.
4/5/20XX
07:30
Initial physical assessment reveals:
CV: WNL+ 2 pulses in all extremities. Capillary refill < 3 seconds.
Resp: Breath sounds clear on room air all lobes, no retractions or upper airway noise,
good aeration.
GI: bowel sounds present all quadrants, nasogastric tube secured to R naris.
Integ: Pink and intact except for intravenous (IV) 24 g right forearm infusing D5 1/2 with
KCl 20 mEq/L at 49 ml/hr., site w/o redness or edema; puncture wounds from lab draws.
ENT: mucous membranes moist and intact. Pain FACES 3/5 neck and throat. PEWS 1.
VS: BP 124/70, T 37 (98.6 F), P 95, RR 24 , O2 sat 100%
For each client finding below, click to specify if the finding is consistent with
the disease process of tonsillitis, pneumonia, or epiglottitis. Each finding may
support more than one disease process. Note: Each column must have at least
one response option selected.
Common clinical manifestations include:
• tonsillitis
• red, swollen tonsils
• white or yellow patches on the tonsils
• sore throat
• difficulty or painful swallowing
• enlarged tender glands (lymph nodes) in the neck
• scratchy, muffled, or throaty voice
• neck pain or stiff neck
• headache
• fever may or may not occur
• pneumonia
• cough with yellow or green sputum
• fever
• sweating
• chills
• shortness of breath
• wheezing or adventitious breath sounds
• rapid, shallow breathing
• sharp or stabbing chest pain that gets worse when deep breathing or coughing
• loss of appetite
• low energy
• fatigue
• nausea and vomiting especially in small children
