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.

Frequent swallowing.

Blood-tinged mucus.

Dark brown emesis.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

A sore throat is a common and expected finding after a tonsillectomy due to irritation from the procedure. While it can cause discomfort, it is not a priority concern unless it worsens significantly or is accompanied by other symptoms indicating complications such as bleeding or infection.

Choice B rationale:

Frequent swallowing can be a sign of bleeding after a tonsillectomy. The child may swallow more often to clear blood or blood clots from the throat, which could indicate that there is active bleeding from the surgical site.

Choice C rationale:

Blood-tinged mucus is a common finding in the immediate postoperative period after a tonsillectomy. It is expected due to the healing process and is not a cause for concern unless it becomes profuse or is accompanied by active bleeding.

Choice D rationale:

While dark brown vomit may indicate that the child has swallowed blood, it is not as immediately concerning as frequent swallowing, which could suggest active bleeding at the surgical site. Dark brown emesis is typically less alarming, but it should still be monitored closely.

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Correct Answer is D

Explanation

A. Placing a pillow under the client's knees would not specifically address preventing a compromise in placental blood flow.
B. Reverse Trendelenburg involves tilting the bed so that the head is elevated and the feet are lower. While this position may help with respiratory difficulties (by allowing the diaphragm to expand), it does not address the concern of aortocaval compression, which is critical during pregnancy.
C. The lithotomy position is used for vaginal deliveries and involves placing the client's feet in stirrups, which is not appropriate for a cesarean birth.
D. The wedge position helps maintain blood flow to the placenta by relieving aortocaval compression, thereby improving venous return and placental perfusion. This is particularly important in pregnant clients, where the uterus can exert significant pressure on these blood vessels in the supine position.

A. "The client might act seductively." B. "The client is overly concerned about minor details." C. "The client exhibits impulsive behavior." D. "The client is exceptionally clingy to others."

Correct Answer is C

Explanation

A. Incorrect. Acting seductively is more characteristic of histrionic personality disorder.
B. Incorrect. Being overly concerned about minor details is more characteristic of obsessive-compulsive personality disorder.
C. Correct. Impulsive behavior, such as reckless spending or self-harm, is a common feature of borderline personality disorder.
D. Incorrect. Being exceptionally clingy to others is not a defining feature of borderline personality disorder.

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A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?

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A nurse is assessing a child who is postoperative following a tonsillectomy.
Which of the following findings should the nurse identify as the priority?