A nurse is caring for a 5-year-old child who is 3 hours post-operative uncomplicated tonsillectomy. Which of the following actions are appropriate post op care? (SELECT ALL THAT APPLY)
Promote quiet activities and rest
Provide liquids with straws
Closely monitor ABC
Monitor and treat pain
Apply ice collar as ordered
Correct Answer : A,C,D,E
A. Quiet activities and rest should be promoted to ensure the child is not overstimulated and to allow for proper recovery.
B. Liquids should be given without straws to avoid potential injury to the surgical site.
C. Monitoring the airway, breathing, and circulation (ABC) is essential, particularly in the first few hours post-surgery.
D. Pain management is critical to ensure the child’s comfort and to help with healing.
E. Applying an ice collar can help reduce swelling and pain after a tonsillectomy.
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Related Questions
Correct Answer is C
Explanation
A. Distended neck veins are typically seen in cases of heart failure or other circulatory issues, not pyloric stenosis.
B. Red currant jelly stools are associated with intussusception, not pyloric stenosis.
C. Weight loss is a common manifestation of pyloric stenosis due to vomiting and poor nutrient intake. This occurs as the narrowing of the pylorus obstructs the passage of food.
D. Occasional vomiting could be a sign of pyloric stenosis, but the hallmark feature is projectile vomiting, which occurs more frequently and is often more forceful.
Correct Answer is A
Explanation
A. It is normal for toddlers to exhibit defiance, say "no" often, and become upset when scolded as part of the development of autonomy and independence. Seeking comfort afterward is also typical.
B. While the toddler may be struggling with emotional regulation, this behavior is typical and does not necessarily indicate ineffective coping.
C. There is no indication that further assessment is necessary unless other concerns arise. This behavior is normal for the developmental stage.
D. The toddler's behavior is not necessarily due to unmet affection; it is more likely part of the developmental process.
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