When caring for a patient that has undergone a tonsillectomy, the nurse's priority assessment in identifying a potential complication would include?
Assess breathing pattern for snoring.
Assess mucous membranes for moisture.
Assess pain level.
Observe for continuous swallowing.
The Correct Answer is D
A. While changes in breathing patterns can indicate airway obstruction, snoring alone is not the most specific indicator of a complication after tonsillectomy. It could indicate swelling or an obstructed airway but does not specifically indicate bleeding.
B. Checking the mucous membranes for moisture is important in general nursing care to assess hydration status. However, it is not the most immediate priority in the post-tonsillectomy setting, where the primary concern is to monitor for bleeding.
C. Assessing pain is important for overall patient comfort and to evaluate the effectiveness of pain management strategies. However, pain alone does not directly indicate a complication like bleeding, which is a critical concern in this scenario.
D. Continuous swallowing can be an early sign of bleeding after tonsillectomy, as patients may swallow frequently to clear blood from the throat. If a patient is swallowing more often than normal, it could indicate that they are swallowing blood, which would require immediate intervention.
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Related Questions
Correct Answer is C
Explanation
A. While keeping the infant content is important for overall well-being, it's not the primary focus for eczema care.
B. Antibiotics are not typically used for eczema, as it's not a bacterial infection.
C. Eczema can cause the skin to become cracked and open, making it susceptible to infection. Therefore, preventing infection is a priority.
D. While good nutrition is important for overall health, it's not the primary concern in managing eczema
Correct Answer is A
Explanation
A. A fracture involving the epiphyseal plate (growth plate) can lead to differential growth in the affected limb. If a fracture occurs before the growth plate has closed, it can potentially result in the shorter leg as the growth in that limb may be inhibited compared to the unaffected leg.
B. While scoliosis can lead to asymmetrical body positioning and potentially cause a perception of leg length discrepancy, it does not typically cause a true difference in bone length. Instead, scoliosis affects the spine's curvature and may alter posture, but it’s not a direct cause of one leg being shorter than the
other.
C. A comminuted clavicle fracture primarily affects the shoulder and does not impact leg length. It involves the upper limb and does not contribute to any differences in the lengths of the legs, making this option irrelevant to the observed leg length discrepancy.
D. JIA can lead to joint inflammation and may affect limb growth if it causes significant damage to the joints. However, while it can potentially cause some discrepancies in limb length due to joint issues, it is less directly associated with one leg being shorter than the other compared to an epiphyseal plate fracture.
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