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A nurse on a pediatric unit is caring for a preschooler who is postoperative following an appendectomy.

Exhibits

Complete the following sentence by using the lists of options.

The child is at risk for developing

as evidenced by their. and.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A","dropdown-group-3":"C"}

  • Postoperative ileus: Ileus is a common complication after abdominal surgery due to anesthesia, opioid use, and limited mobility. It presents as delayed return of bowel function, marked by absent bowel sounds and abdominal discomfort. In this case, the child has absent bowel sounds and increasing tenderness, supporting this risk.
  • Atelectasis: Atelectasis generally presents with diminished breath sounds and hypoxia, not clear breath sounds. Although the child has shallow respirations and is refusing the incentive spirometer, there are no respiratory findings such as decreased oxygen saturation or adventitious breath sounds that support this condition currently.
  • Peritonitis: Peritonitis would present with systemic symptoms like fever, severe abdominal pain, rebound tenderness, or signs of sepsis. The child has mild abdominal tenderness and stable vital signs, which do not indicate peritoneal inflammation at this time.
  • Urinary retention: This would be characterized by lack of urination, bladder distension, or discomfort—none of which are noted in the scenario. The child’s urinary output and bladder status are not identified as concerns, making this diagnosis unlikely.
  • Absent bowel sounds:  This is a key clinical sign of ileus. After surgery, bowel activity should return gradually. Continued absence of sounds, especially along with abdominal tenderness, strongly indicates impaired gastrointestinal motility.
  • Shallow respirations: While shallow breathing is often a contributing factor to respiratory complications, in the context of abdominal surgery, it also limits diaphragmatic movement, which can further suppress bowel activity and contribute to postoperative ileus.
  • Clear breath sounds:  This is a normal respiratory finding and does not support the presence of atelectasis or other pulmonary complications. It suggests that lung fields are adequately ventilated despite shallow breathing.
  • Intact abdominal dressing: This is an expected postoperative finding and does not support a diagnosis of infection, wound complication, or ileus. It indicates proper surgical wound healing.


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Related Questions

Correct Answer is A

Explanation

A. Screen the child's visitors for active infections. Neutropenia places the child at high risk for infection due to a severely weakened immune system. Screening visitors for signs of illness is essential to minimize exposure to infectious agents.
B. Prepare the child for a platelet transfusion. Platelet transfusions are used to treat thrombocytopenia, not neutropenia. While leukemia may cause both conditions, neutropenia specifically increases infection risk, not bleeding risk.
C. Monitor the child for indications of active bleeding. While bleeding is a concern in leukemia, it is more directly linked to low platelet levels. The priority intervention for neutropenia is infection prevention, not bleeding control.
D. Initiate a low-protein diet for the child. A low-protein diet is not appropriate for a child with leukemia. These children need adequate protein for healing, immune support, and maintaining strength during treatment.

Correct Answer is D

Explanation

A. Emphasize vowel sounds when speaking. Consonants are typically more difficult to hear than vowels, and overemphasizing vowels can distort speech and make it harder to understand. Clear, natural enunciation is more effective.
B. Sit next to the client when speaking to them. Sitting in front of the client is more effective, as it allows the client to read lips and observe facial expressions, both of which are important in supporting communication for individuals with hearing loss.
C. Lower the tone of voice at the end of each sentence. Lowering pitch or volume at the end of sentences can make speech harder to follow. A steady, moderate tone throughout conversation is more helpful and easier to understand.
D. Decrease background noise when talking with the client. Reducing environmental noise helps the client focus on the speaker’s voice, improving their ability to hear and comprehend the message. It’s one of the most effective strategies in communication with hearing-impaired individuals.

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