Medical Surgical Tonsillitis #4

Question

The nurse is caring for a client with a peritonsillar abscess scheduled for needle aspiration who is complaining of sudden onset symptoms of chills, difficulty breathing, and a productive cough. Vital check reveals a temperature of 103.2 F (39.6 C), respiratory rate of 26, pulse of 120 and blood pressure of 136/89. The nurse is concerned for which complication of peritonsillar abscess?

Answers

  1. Pleural effusion
    • Rationale:

      This answer is not correct because symptoms of pleural effusion are chest pain, a dry, nonproductive cough, labored breathing, and orthopnea. This client is experiencing a productive cough and rapid breathing, not labored breathing. Pleural effusion is a complication of pneumonia.

  2. Sepsis
    • Rationale:

      This answer is not correct because although these symptoms are similar to symptoms that present with sepsis, the client is experiencing no mental status changes and the blood pressure is not concerning. The fact that the client has a productive cough and that pneumonia is a common complication of peritonsillar abscess suggests pneumonia, not sepsis.

  3. Pneumonia
    • Rationale:

      This answer is correct because these symptoms indicate pneumonia. Pneumonia is a common complication of peritonsillar abscess. If the abscess ruptures, and its contents travel into the lungs, this will cause a bacterial infection. Symptoms of pneumonia can occur suddenly and include fever and chills, difficult and rapid breathing, cough, and chest pain.

  4. Airway obstruction
    • Rationale:

      This answer is not correct because although a peritonsillar abscess can cause an airway obstruction, these symptoms the client is experiencing do not indicate an airway obstruction. Airway obstruction symptoms include fidgeting, choking, unusual breathing noises, confusion, and cyanosis.

Overview

A client being treated for peritonsillar abscess who experiences sudden onset of chills, shortness of breath, and cough has most likely developed pneumonia. Pneumonia occurs when the abscess ruptures and its contents travel into the lungs.

Explanation

Learning Outcomes

A client being treated for peritonsillar abscess who experiences sudden onset of chills, shortness of breath, and cough has most likely developed pneumonia. Pneumonia occurs when the abscess ruptures and its contents travel into the lungs. Symptoms can appear suddenly and include fever and chills, difficult and rapid breathing, cough, and chest pain. Assessment findings may reveal fever, increased respiratory rate, increased pulse, productive cough, decreased breath sounds, and lung crackles. Pleural effusion causes chest pain, nonproductive cough, and labored breathing. With sepsis, there will most likely be a mental status change and a noticeable change in all vital signs. Someone with an airway obstruction may become agitated, and fidget, choke, make unusual breathing noises, be confused, and cyanotic.

Test Taking Tip

Know symptoms of illnesses and how the vitals will correlate. Know which complications occur as a result of an illness.

Video Rationale