A nurse is caring for a 5-year-old child who is 3 hours post-operative uncomplicated tonsillectomy. Which of the following actions are appropriate post op care? (SELECT ALL THAT APPLY)
Promote quiet activities and rest
Provide liquids with straws
Closely monitor ABC
Monitor and treat pain
Apply ice collar as ordered
Correct Answer : A,C,D,E
A. Quiet activities and rest should be promoted to ensure the child is not overstimulated and to allow for proper recovery.
B. Liquids should be given without straws to avoid potential injury to the surgical site.
C. Monitoring the airway, breathing, and circulation (ABC) is essential, particularly in the first few hours post-surgery.
D. Pain management is critical to ensure the child’s comfort and to help with healing.
E. Applying an ice collar can help reduce swelling and pain after a tonsillectomy.
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Related Questions
Correct Answer is A
Explanation
A. Allowing the child to make decisions about their care helps foster autonomy, which is important in the stage of development described by Erikson for children at this age.
B. While a structured routine is helpful, fostering a sense of independence and decision-making is key to promoting development at this stage.
C. Expressing feelings through creative activities is beneficial but does not address the developmental need for independence and autonomy.
D. Engaging with other children is important for social development, but allowing the child to have some control over their care is essential for psychosocial growth.
Correct Answer is C
Explanation
A. While strabismus may be treated with interventions such as patching, it is not always immediately concerning in newborns. The nurse should first provide accurate information about normal development.
B. Taking the baby to the nursery may not be necessary unless the child’s condition worsens or there is a
clear concern. A thorough assessment and explanation by the nurse are more appropriate.
C. Strabismus is common in newborns due to the immaturity of eye muscle control and usually resolves as the child develops. This is the most therapeutic response as it provides reassurance based on developmental norms.
D. Calling the primary care provider might be premature unless the nurse identifies a significant concern beyond normal development.
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