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

Answer and Explanation

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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Correct Answer is D

Explanation

When caring for a child with acute appendicitis, the nurse should anticipate an elevated white blood cell count (WBC) in the laboratory values. A high WBC count is a common finding in acute appendicitis, as it indicates an inflammatory response and infection in the body. The body's immune system responds to the inflammation caused by the infected appendix, leading to an increase in WBCs to fight off the infection.
The other options are not necessarily specific to acute appendicitis:
A. RBC 4.2 million/mm³: The red blood cell count (RBC) measures the number of red blood cells in the bloodstream. This value may be within the normal range, but it is not the primary marker for diagnosing or monitoring acute appendicitis.
B. Lymphocytes 3,000/mm3: Lymphocytes are a type of white blood cell involved in the body's immune response. While changes in lymphocyte levels can occur during inflammation, it is not the primary marker for diagnosing or monitoring acute appendicitis.
C. Neutrophils 3.000/mm³: Neutrophils are a type of white blood cell that increases in response to infection and inflammation. However, the absolute neutrophil count is not as relevant as the overall WBC count in determining the presence and severity of acute appendicitis.

A. "This is within the expected range for your baby." B. "The fever is causing an increase in your baby's heart rate." C. "As your baby begins to fall asleep. his heart rate will decrease." D. "Your baby's heart is beating fast in an attempt to cool down his body."

Correct Answer is B

Explanation

In this scenario, the infant has a heart rate of 190/min and a fever of 40°C (104°F). Fever in infants can cause an increase in heart rate, which is a normal physiological response to elevated body temperature. Fever is the body's way of responding to an infection or illness, and it triggers various physiological changes, including an increase in heart rate. This helps the body to circulate blood and deliver immune cells to fight off the infection.
The other options are not accurate or relevant to the infant's current condition:
A. "This is within the expected range for your baby." - A heart rate of 190/min is above the normal expected range for a 2-month-old infant, which is typically between 120 to 160 beats per minute. This response would not address the elevated heart rate and fever.
C. "As your baby begins to fall asleep, his heart rate will decrease." - While heart rate may decrease during sleep, it does not explain the elevated heart rate and fever observed in this situation.
D. "Your baby's heart is beating fast in an attempt to cool down his body." - While tachycardia (fast heart rate) can be associated with increased metabolic demands during fever, the main reason for the increased heart rate in this case is the fever itself, not the body's attempt to cool down. Fever is a response to infection or illness and can cause an increase in heart rate as part of the body's normal immune response.

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A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings is a manifestation of hemorrhage?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has acute appendicitis. Which of the following results should the nurse anticipate when reviewing this client's laboratory values?

Correct Answer is D

Explanation

A nurse is obtaining vital signs from a 2-month-old infant. The infant's heart rate is 190/min and his temperature is 40° C (104° F). The father asks the nurse why the infant's heart is beating so fast. Which of the following responses by the nurse is appropriate?

Correct Answer is B

Explanation

A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings is a manifestation of hemorrhage?

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