A nurse is assessing a preschool-age child who is in the immediate postoperative period following a tonsillectomy. Which of the following assessment findings is the priority?
The child's throat pain increases.
The child refuses clear liquids.
The child cries often.
The child swallows frequently.
The Correct Answer is D
Rationale:
A. The child's throat pain is expected post-tonsillectomy and can be managed using analgesics or an ice collar. However, this is not a priority finding compared to frequent swallowing which may indicate bleeding which is a life-threatening complication of tonsillectomy.
B. Refusing clear liquids may indicate discomfort but is not as urgent as a potential increase in throat pain.
C. Crying often may be a response to discomfort but does not necessarily indicate a complication requiring immediate intervention.
D. This assessment finding indicates that the child might have bleeding in the throat, which is a life-threatening complication of tonsillectomy. The nurse should
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Salicylic acid is contraindicated for children under 12 years old because it can cause Reye's syndrome, a rare but serious condition that affects the brain and liver.
B. Sulfamethoxazole and trimethoprim is an antibiotic that is commonly used to treat UTIs caused by bacteria such as E. coli. It is anticipated for this client because it can help clear the infection and reduce the symptoms.
C. Proper perineal hygiene is important for preventing UTIs, especially in girls who have a shorter urethra than boys. The nurse should educate the child about wiping from front to back after using the toilet, avoiding bubble baths and scented products, and changing underwear daily.
D. Sunscreen is advised for clients taking sulfamethoxazole and trimethoprim because this medication can increase the sensitivity of the skin to sunlight and cause sunburns or rashes.
E. Fluid restriction is contraindicated for clients with UTIs because it can increase the concentration of bacteria in the urine and worsen the infection. The nurse should ensure that the child drinks plenty of fluids, such as water, juice, or milk, to flush out the bacteria and dilute the urine.
Correct Answer is C
Explanation
Rationale:
A. Visual analog scales rely on the child's ability to comprehend and interpret visual cues, which may be challenging for a cognitively impaired toddler.
B. FACES scales require the child to identify their pain level based on facial expressions, which may also be challenging for a cognitively impaired toddler.
C. FLACC (Face, Legs, Activity, Cry, Consolability) scales are specifically designed for non-verbal or cognitively impaired individuals, assessing pain based on observable behaviors such as facial expression, leg movement, activity level, cry, and ability to be consoled.
D. CRIES scales are primarily used for assessing pain in newborns and infants and may not be as applicable for a cognitively impaired toddler.
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