A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?
Frequent swallowing
Dark brown emesis
Sore throat
Blood-tinged mucus
The Correct Answer is A
Answer: A
Rationale:
A. Frequent swallowing: Frequent swallowing in a postoperative tonsillectomy patient can be a sign of bleeding or a hemorrhage. This is a priority finding because it may indicate that the child is swallowing blood, which requires immediate intervention to prevent significant blood loss and complications.
B. Dark brown emesis: Dark brown emesis can be a normal finding post-tonsillectomy, as it may indicate the presence of old blood or clotted blood. While it should be monitored, it is not as urgent as frequent swallowing, which may signify active bleeding.
C. Sore throat: A sore throat is a common postoperative symptom following a tonsillectomy and is generally expected. It is important to manage pain and discomfort, but it is not as urgent as signs of potential bleeding.
D. Blood-tinged mucus: Blood-tinged mucus can occur after a tonsillectomy due to irritation or minor bleeding. While it should be observed, it is less critical compared to frequent swallowing, which may indicate more significant bleeding.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Adding water to the formula will decrease its osmolarity, reducing the risk of hyperosmolar dehydration. This action helps to dilute the formula and make it more isotonic, which is better tolerated by the client's gastrointestinal tract.
B. Repositioning the NG tube may be necessary if there are issues with tube placement or if the tube has migrated. However, it is not directly related to addressing hyperosmolar dehydration.
C. Increasing the rate of formula delivery may exacerbate hyperosmolar dehydration by introducing more concentrated formula into the gastrointestinal tract, leading to further dehydration.
D. Switching to a lactose-free formula may be appropriate if the client has lactose intolerance, but it does not address the issue of hyperosmolar dehydration. Adding water to the formula is the more appropriate intervention in this scenario to decrease osmolarity and prevent dehydration.
Correct Answer is B
Explanation
A. "Think about a positive outcome to a stressful situation." - This instruction describes a cognitive restructuring technique, which involves reframing negative thoughts with positive ones. While cognitive restructuring can be helpful for managing stress and anxiety, it is not specifically related to progressive relaxation.
B. "Tighten a muscle group, then release the tension and move to the next one." - This is the correct instruction for progressive relaxation. Progressive relaxation involves systematically tensing and relaxing muscle groups throughout the body to reduce physical tension and promote relaxation. By sequentially tensing and releasing muscle groups, the client learns to recognize and control muscle tension, which can help alleviate stress and anxiety.
C. "Focus on a pleasant memory and express your emotions in writing." - This instruction describes a journaling or expressive writing technique, which can be beneficial for processing emotions and reducing stress. However, it is not specific to progressive relaxation.
D. "Picture taking the stress you feel and pushing it down and out of your feet." - This instruction describes a visualization or imagery technique, where the client visualizes releasing stress from the body. While visualization can be a component of relaxation exercises, it is not specifically associated with progressive relaxation, which focuses on muscle tension and relaxation.
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