A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings is a manifestation of hemorrhage?
increased pain
Frequent swallowing
Poor fluid intake
Drooling
The Correct Answer is B
Correct answer: B
A. Increased pain: Increased pain is a common and expected finding after a tonsillectomy. The surgical removal of tonsils creates wounds in the throat, which can cause discomfort and pain during the healing process. However, increased pain alone is not a specific manifestation of hemorrhage. Hemorrhage would be indicated by other signs, such as drooling, frequent swallowing, or vomiting blood.
B. Frequent swallowing: This can indicate that the child is swallowing blood, which is a common sign of bleeding at the surgical site. Children might not always show obvious signs of bleeding in the mouth, so frequent swallowing can be a subtle but critical indicator of hemorrhage.
C. Poor fluid intake: Poor fluid intake is a common concern after a tonsillectomy due to postoperative pain and discomfort in the throat. The child may be reluctant to drink or eat initially because of their sore throat. However, poor fluid intake alone is not an indicative sign of hemorrhage. Hemorrhage would present with other symptoms, such as drooling, frequent swallowing, or vomiting blood.
D. Drooling: While drooling can occur due to discomfort, pain, or difficulty swallowing, it is not as specific or immediate a sign of hemorrhage as frequent swallowing.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should clarify the prescription to administer sodium biphosphate/sodium phosphate because it is a laxative and is contraindicated in a child with suspected appendicitis. The use of laxatives or enemas can potentially worsen the condition by increasing the risk of perforation or rupture of the inflamed appendix.
A. Monitoring oral temperature every 4 hours is important to assess for signs of infection or worsening condition.
C. Maintaining NPO status is essential to avoid stimulating the digestive system and to prepare for possible surgery.
D. Medicating the client for pain every 4 hours as needed is appropriate to manage pain and provide comfort while the child awaits further evaluation or treatment.
Remember, it's crucial to avoid the use of laxatives, enemas, or any other interventions that can potentially aggravate the inflamed appendix in a child with suspected appendicitis.
Correct Answer is B
Explanation
When providing teaching to a parent of a child with celiac disease, the nurse should recommend food choices that are gluten-free. Celiac disease is an autoimmune disorder triggered by the ingestion of gluten, which is a protein found in wheat, barley, rye, and their derivatives. Gluten damages the small intestine lining in individuals with celiac disease, leading to various gastrointestinal and nutritional issues.
The correct food choice for a child with celiac disease is B. Rice. Rice is naturally gluten-free and can be a safe and nutritious option for individuals with celiac disease. Other gluten-free options include corn, quinoa, oats (certified gluten-free oats), potatoes, and many fruits and vegetables.
A. Barley: Barley contains gluten, which is harmful to individuals with celiac disease. It should be avoided in the child's diet.
C. Rye: Rye also contains gluten and should be avoided in the child's diet. It can cause damage to the small intestine in individuals with celiac disease.
D. Wheat: Wheat is a primary source of gluten and is strictly off-limits for individuals with celiac disease. It is essential to avoid all wheat-containing products, including bread, pasta, and baked goods.
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