A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?

Relieve the client's pain.

Promote oral hygiene

Ensure adequate nutrition

Prevent aspiration

Answer and Explanation

The Correct Answer is D

A. Relieve the client's pain: While pain management is important for client comfort and recovery, it is not the priority immediately following intermaxillary fixation. Pain relief can be addressed once the more urgent concerns, such as preventing aspiration, are addressed.
B. Promote oral hygiene: Promoting oral hygiene is essential for preventing complications such as infection, but it is not the priority immediately after surgery and intermaxillary fixation. The client's airway and respiratory status should be the primary focus at this time.
C. Ensure adequate nutrition: Ensuring adequate nutrition is important for the client's overall recovery, but it is not the immediate priority after surgery and intermaxillary fixation. The priority is to prevent complications such as aspiration and maintain the client's airway.
D. Prevent aspiration: This is the priority action for the nurse. Intermaxillary fixation restricts the client's ability to open their mouth, increasing the risk of aspiration if vomiting occurs. The nurse should ensure that the client's airway is clear and that measures are in place to prevent aspiration, such as positioning the client appropriately and monitoring for signs of respiratory distress.

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Correct Answer is D

Explanation

A. Battery involves the unauthorized or harmful touching of another person without their consent. Restraint without proper justification could potentially lead to a charge of battery, but the situation described does not involve actual physical contact.
B. Assault involves the threat of bodily harm to another person, creating fear or apprehension that the harm will be carried out. While the threat of restraint might cause fear, actual restraint is necessary to constitute assault.
C. Invasion of privacy refers to the unauthorized intrusion into an individual's private affairs or the public disclosure of private information. It does not apply to the act of physically restraining a client.
D. False imprisonment occurs when an individual is unlawfully restrained or confined against their will. In this scenario, the provider's directive to restrain the client against her wishes constitutes false imprisonment if the restraint is not justified by the client's medical condition or pose an immediate danger to herself or others.

A. Superficial palpation B. Auscultation C. Inspection D. Deep palpation

Correct Answer is C,B,A,D

Explanation

Inspection:This is the first step because it allows the nurse to gather information through observation without causing any discomfort to the child. It involves looking at the child's abdomen for any visible abnormalities like distension, asymmetry, masses, or discoloration.

Auscultation:After inspection, the nurse listens to the bowel sounds using a stethoscope. This helps assess peristalsis (movement of food through the intestines) and identify potential problems like bowel obstruction or decreased motility.

Superficial Palpation:This gentle palpation helps assess muscle tone, tenderness, and masses. It's performed after auscultation to avoid altering bowel sounds. Since children are often apprehensive about abdominal exams, starting with a gentler touch can help them feel more comfortable.

Deep Palpation (if necessary):Deep palpation is reserved for last as it can be more uncomfortable for the child. It's used to assess for organomegaly (enlarged organs) or masses that may not be palpable with superficial palpation. It's only performed if there are indications from the first three steps.

Here's a breakdown of why this order is important:

Minimize Discomfort:Starting with non-invasive methods like inspection and auscultation helps establish trust and reduces anxiety in the child, making the overall assessment more cooperative.

Maintain Baseline Bowel Sounds:Palpation can alter bowel sounds, so it's important to listen to them first to get an accurate baseline.

Gradual Progression:Moving from gentle to deeper palpation allows the child to adjust to the sensation and helps the nurse identify potential areas of tenderness before applying deeper pressure.

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A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is C,B,A,D

Explanation

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