The nurse is doing discharge teaching for a child who has had a tonsillectomy. The nurse tells the client and family that the child should have plenty of fluids. In addition, the nurse would explain to the child’s caregiver that the child may:
Be given ice cream and milk the first postoperative day because these foods make swallowing easier.
Have a painful earache around the third day postoperatively but the earache will be gone by the fourth day.
Vomit dark old blood but the caregiver should call the clinic if the child has bleeding between the fifth and seventh days postoperatively.
Have severe throat pain for up to 2 weeks postoperatively; this is not a concern.
The Correct Answer is C
Choice A reason: Ice cream and milk may coat the throat, increasing mucus and infection risk post-tonsillectomy. Vomiting dark blood is normal, but new bleeding requires attention, making this incorrect, as dairy is not recommended for easing swallowing in the immediate postoperative period for the child.
Choice B reason: Earache from referred pain is common post-tonsillectomy but may persist beyond the fourth day. Vomiting old blood with guidance on new bleeding is more accurate, making this incorrect, as it underestimates the duration and management of ear pain in the recovery period.
Choice C reason: Vomiting dark old blood is normal post-tonsillectomy due to swallowed blood, but fresh bleeding between days 5-7 indicates potential complications, requiring clinic contact. This aligns with pediatric postoperative care, making it the correct explanation for caregivers during discharge teaching for the child.
Choice D reason: Severe throat pain for 2 weeks is expected but should be monitored, not dismissed, as it may signal complications. Guidance on bleeding is more critical, making this incorrect, as it downplays the need for vigilance regarding pain in the postoperative recovery period.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Discussing anxiety and depression is relevant but premature without addressing the immediate issue of the child being alone and scared after school. After-school programs provide supervision and safety, making this less urgent and incorrect compared to resolving the primary concern of unsupervised time for the child.
Choice B reason: Preventing drug and alcohol use is important but not the priority for a 10-year-old scared and alone after school. After-school programs address immediate safety and social needs, making this secondary and incorrect compared to tackling the child’s current unsupervised and fearful situation at home.
Choice C reason: Emergency contact numbers are useful but do not resolve the ongoing issue of the child being alone and scared daily. After-school programs offer structured supervision, directly addressing the primary concern, making this less critical and incorrect for the nurse’s priority action for this family.
Choice D reason: Providing a list of after-school programs addresses the child’s fear and isolation by offering supervised, engaging activities, reducing unsupervised time at home. This prioritizes safety and emotional well-being, aligning with pediatric nursing goals for supporting relocated families, making it the correct action to assist them.
Correct Answer is D
Explanation
Choice A reason: Asking the child about seeing her mother places an unfair burden on her, especially post-accident when she may be distressed. Verifying legal contact permissions ensures compliance with custody agreements, making this inappropriate and incorrect compared to confirming authorized visitors in this sensitive situation.
Choice B reason: Directing the mother to the room without checking custody status risks violating legal restrictions, potentially escalating conflict. Confirming who is allowed contact protects the child, making this hasty and incorrect compared to the nurse’s responsibility to verify permissions in a divorce-related hospital scenario.
Choice C reason: Asking the mother about her permission may be unreliable, as agitation could lead to inaccurate claims. Checking official records ensures adherence to custody orders, making this inadequate and incorrect compared to the nurse’s duty to verify authorized contact for the hospitalized child objectively.
Choice D reason: Checking who is allowed contact verifies legal custody arrangements, ensuring the child’s safety and compliance with court orders in a divorce situation. This aligns with pediatric hospital protocols, making it the most appropriate action to address the mother’s demand while protecting the injured daughter.
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