A nurse is caring for a child in the PACU following a tonsillectomy. Which of the following findings requires immediate intervention by the nurse?
Dark brown blood noted in emesis
Axillary temperature 38° C (100° F)
Child reports pain level of 5 on the FACES scale
Frequent swallowing
The Correct Answer is D
A. Dark brown blood in emesis is expected postoperatively due to swallowed blood and does not require immediate intervention.
B. A mild fever (38°C or 100°F) can occur postoperatively and is not an emergency.
C. Pain is expected after a tonsillectomy and should be managed but does not require immediate intervention.
D. Frequent swallowing may indicate active bleeding from the surgical site, which requires immediate assessment and intervention.
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Related Questions
Correct Answer is B
Explanation
A. A preschool-age child is not expected to give a logical explanation for death. They may not fully understand the concept of death in the same way an older child or adult does.
B. Correct. It is common for preschool-age children to be curious about what happens to the body after death. This curiosity is an age-appropriate response to death.
C. A preschool-age child may not fully grasp the concept of death as permanent. They may have limited understanding of the irreversibility of death.
D. Feeling responsible for a sibling's death would be an inappropriate and potentially concerning response for a preschool-age child. It may indicate a need for further assessment and support.
Correct Answer is B
Explanation
A. Increased self-esteem is a positive aspect of development, but it may not be a consistent characteristic during early adolescence. Self-esteem can fluctuate based on various factors.
B. Mood swings are common during early adolescence due to hormonal changes and the emotional challenges that come with this stage of development. It's important for parents to be understanding and supportive during this time.
C. The growth rate during early adolescence may vary from person to person, but it generally accelerates rather than decelerates. This period is associated with rapid physical growth, known as the adolescent growth spurt.
D. Emotional separation from parents is a normal part of adolescent development, but it tends to become more prominent in later adolescence rather than early adolescence. During early adolescence, there may be a mix of seeking independence and still relying on parental support and guidance.
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