A nurse is teaching a client who is postpartum about caring for their newborn's umbilical cord. Which of the following instructions should the nurse include?

Answer: A

Rationale:

A. Frequent swallowing: Frequent swallowing in a postoperative tonsillectomy patient can be a sign of bleeding or a hemorrhage. This is a priority finding because it may indicate that the child is swallowing blood, which requires immediate intervention to prevent significant blood loss and complications.

B. Dark brown emesis: Dark brown emesis can be a normal finding post-tonsillectomy, as it may indicate the presence of old blood or clotted blood. While it should be monitored, it is not as urgent as frequent swallowing, which may signify active bleeding.

C. Sore throat: A sore throat is a common postoperative symptom following a tonsillectomy and is generally expected. It is important to manage pain and discomfort, but it is not as urgent as signs of potential bleeding.

D. Blood-tinged mucus: Blood-tinged mucus can occur after a tonsillectomy due to irritation or minor bleeding. While it should be observed, it is less critical compared to frequent swallowing, which may indicate more significant bleeding.

A. "Did anything in particular make you feel this way?" - While exploring potential triggers for the client's feelings of uselessness is important, assessing for suicidal ideation takes precedence. However, this question can be asked after addressing the immediate safety concern.
B. "Do you ever think about harming yourself?" - This is the priority assessment question. Older adults experiencing feelings of uselessness and worthlessness may be at risk for suicidal ideation or self-harm. Asking about thoughts of self-harm allows the nurse to assess the client's safety and determine the need for immediate intervention.
C. "How long have you had these feelings of uselessness?" - While understanding the duration of the client's feelings is relevant, assessing for suicidal ideation is more critical in ensuring the client's safety.
D. "Would you tell me more about the changes you see in your body?" - Exploring the client's perception of physical changes is important for addressing body image concerns and promoting self-esteem. However, assessing for suicidal ideation takes precedence as it addresses the client's immediate safety.