A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?
Sore throat
Dark brown emesis
Blood-tinged mucus
Frequent swallowing
The Correct Answer is D
A. Sore throat. This is incorrect because a sore throat is an expected postoperative finding following a tonsillectomy and does not indicate a complication.
B. Dark brown emesis. This is incorrect because dark brown emesis may be swallowed blood from surgery and is not necessarily an immediate concern unless it continues or turns bright red.
C. Blood-tinged mucus. This is incorrect because small amounts of blood-tinged mucus are normal after a tonsillectomy and do not indicate active bleeding.
D. Frequent swallowing. This is correct because frequent swallowing can indicate active bleeding from the surgical site. Post-tonsillectomy hemorrhage is a serious complication that requires immediate intervention.
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Related Questions
Correct Answer is A
Explanation
A. A bluish-white colored pupil. This is correct because cataracts cause clouding of the lens, leading to a grayish or bluish-white appearance of the pupil. This opacity gradually impairs vision.
B. Decrease in peripheral vision. This is incorrect because a loss of peripheral vision is characteristic of glaucoma, not cataracts.
C. Increased intraocular pressure. This is incorrect because increased intraocular pressure is a hallmark of glaucoma, not cataracts.
D. Loss of central vision. This is incorrect because central vision loss is associated with macular degeneration rather than cataracts.
Correct Answer is C
Explanation
A. "Did anything in particular make you feel this way?" Understanding the cause of the client’s feelings is important, but assessing for immediate safety takes priority.
B. "Would you tell me more about the changes you see in your body?" Exploring the client’s perception of aging is useful, but it does not address potential risk for self-harm.
C. "Do you ever think about harming yourself?" This is the priority assessment question because feelings of worthlessness can indicate depression, which increases the risk of suicide in older adults. Assessing for self-harm ensures immediate safety.
D. "How long have you had these feelings of uselessness?" Identifying the duration of these feelings is relevant, but it is secondary to determining whether the client is at risk for self-harm.
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