A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings is a manifestation of hemorrhage?
increased pain
Frequent swallowing
Poor fluid intake
Drooling
The Correct Answer is B
Correct answer: B
A. Increased pain: Increased pain is a common and expected finding after a tonsillectomy. The surgical removal of tonsils creates wounds in the throat, which can cause discomfort and pain during the healing process. However, increased pain alone is not a specific manifestation of hemorrhage. Hemorrhage would be indicated by other signs, such as drooling, frequent swallowing, or vomiting blood.
B. Frequent swallowing: This can indicate that the child is swallowing blood, which is a common sign of bleeding at the surgical site. Children might not always show obvious signs of bleeding in the mouth, so frequent swallowing can be a subtle but critical indicator of hemorrhage.
C. Poor fluid intake: Poor fluid intake is a common concern after a tonsillectomy due to postoperative pain and discomfort in the throat. The child may be reluctant to drink or eat initially because of their sore throat. However, poor fluid intake alone is not an indicative sign of hemorrhage. Hemorrhage would present with other symptoms, such as drooling, frequent swallowing, or vomiting blood.
D. Drooling: While drooling can occur due to discomfort, pain, or difficulty swallowing, it is not as specific or immediate a sign of hemorrhage as frequent swallowing.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Cystic fibrosis (CF) is a genetic disorder that affects the production and function of certain glands, particularly those that produce mucus and sweat. One of the key aspects of CF management is addressing the pancreatic insufficiency that occurs in many individuals with CF. Due to the impairment of the pancreas, children with CF may have difficulty digesting food properly, especially fats. This can lead to malabsorption of nutrients, poor weight gain, and other nutritional deficiencies.
Pancreatic enzyme replacement therapy is a crucial part of CF management. Pancreatic enzymes are prescribed to help the child digest and absorb essential nutrients, especially fats. The enzymes are typically given with each meal and snack to aid in the breakdown and absorption of nutrients.
The other options are not correct:
A. "We will restrict the amount of salt in our child's food."
Sodium restriction is generally not a focus in CF management unless there are specific indications for it. CF patients may have increased salt losses in sweat, but dietary sodium restriction is not a primary aspect of their care.
B. "I will limit my child's fluid intake."
Fluid intake is important for children with CF to maintain hydration and prevent dehydration. There is no specific need to limit fluid intake unless there are individualized medical reasons for doing so.
C. "I will prepare low-fat meals with limited protein for my child."
Children with CF often require a high-calorie, high-protein diet to maintain adequate nutrition and growth. Restricting fat and protein intake is not typically recommended, as these nutrients are essential for a child's development and well-being. Instead, pancreatic enzymes are used to aid in the digestion and absorption of fats and other nutrients.
Correct Answer is D
Explanation
D. A client's blood pressure changes from 112/60 mm Hg to 90/54 mm Hg when standing.
A significant drop in blood pressure when changing positions from lying to standing may indicate orthostatic hypotension, which can be a sign of dehydration, blood loss, or other underlying medical issues. This can be a cause for concern, especially if the client is an adolescent, as it may lead to decreased perfusion of vital organs and may require immediate medical attention.
The other options are as follows:
A. A client who has a burn injury to an estimated 5% of his leg and is crying - While it's essential to assess and address the client's pain and comfort, this finding does not indicate an immediate need for medical attention. Pain management and wound care can be addressed based on the severity of the burn and the client's pain level.
B. A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation - This finding is concerning, and the nurse should notify the provider to reassess pain management and evaluate for potential complications related to the fracture. However, it may not require immediate medical attention unless there are signs of severe pain or complications.
C. A client who is 1 day postoperative and has a temperature of 37.5° C (99.5° F) - A slight increase in temperature in the immediate postoperative period may not be unusual and can be attributed to the normal inflammatory response after surgery. The nurse should continue monitoring the client's temperature and report any further changes or additional signs of infection or complications to the provider.
Overall, while all findings should be addressed and managed appropriately, the significant drop in blood pressure (option D) should be reported immediately due to the potential implications for the client's overall health and well-being.
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