A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?
Frequent swallowing
Dark brown emesis
Sore throat
Blood-tinged mucus
The Correct Answer is A
Answer: A
Rationale:
A. Frequent swallowing: Frequent swallowing in a postoperative tonsillectomy patient can be a sign of bleeding or a hemorrhage. This is a priority finding because it may indicate that the child is swallowing blood, which requires immediate intervention to prevent significant blood loss and complications.
B. Dark brown emesis: Dark brown emesis can be a normal finding post-tonsillectomy, as it may indicate the presence of old blood or clotted blood. While it should be monitored, it is not as urgent as frequent swallowing, which may signify active bleeding.
C. Sore throat: A sore throat is a common postoperative symptom following a tonsillectomy and is generally expected. It is important to manage pain and discomfort, but it is not as urgent as signs of potential bleeding.
D. Blood-tinged mucus: Blood-tinged mucus can occur after a tonsillectomy due to irritation or minor bleeding. While it should be observed, it is less critical compared to frequent swallowing, which may indicate more significant bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hypertension:
Disulfiram does not typically cause hypertension as an adverse effect. However, consuming alcohol while taking disulfiram can lead to a range of cardiovascular effects, including hypotension rather than hypertension.
B. Headache:
Consuming alcohol while taking disulfiram can result in a severe and rapid onset of symptoms known as the disulfiram-alcohol reaction. Headache is a common symptom of this reaction, along with flushing, nausea, vomiting, and palpitations. Therefore, monitoring for headaches is essential in clients taking disulfiram who report alcohol ingestion.
C. Insomnia:
Insomnia is not a commonly reported adverse effect of disulfiram. The disulfiram-alcohol reaction primarily involves physical symptoms rather than disturbances in sleep patterns.
D. Tinnitus:
Tinnitus, or ringing in the ears, is not a typical adverse effect of disulfiram. However, disulfiram can cause a range of neurological symptoms as part of the disulfiram-alcohol reaction, but tinnitus is not commonly reported.
Correct Answer is C
Explanation
A. Disulfiram: Disulfiram is used in the treatment of alcohol dependence by creating unpleasant effects (such as nausea and vomiting) when alcohol is consumed. It is not indicated for the management of seizures associated with alcohol withdrawal.
B. Acamprosate: Acamprosate is used in the treatment of alcohol dependence to help maintain abstinence by reducing cravings for alcohol. It is not indicated for the management of seizures associated with alcohol withdrawal.
C. Diazepam: Diazepam is a benzodiazepine medication commonly used to treat seizures associated with alcohol withdrawal due to its anticonvulsant properties. It helps to prevent and control seizures by enhancing the effects of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter in the brain.
D. Naltrexone: Naltrexone is used in the treatment of alcohol dependence by reducing the pleasurable effects of alcohol and decreasing the desire to drink. It is not indicated for the management of seizures associated with alcohol withdrawal.
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