While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes.

Which assessment should the nurse implement?

Inspect the posterior oropharynx.

Touch the tonsillar pillars to stimulate the gag reﬂex.

Ask the child to speak to evaluate change in voice tone.

Assess for teeth clenching or grinding.

Answer and Explanation

The Correct Answer is A

The nurse should inspect the posterior oropharynx of a child who is frequently swallowing after tonsillectomy to assess for bleeding or the presence of clots. Swallowing frequently can be a sign of postoperative bleeding, which is a potential complication of tonsillectomy.

Touching the tonsillar pillars to stimulate the gag reﬂex or asking the child to speak would not provide information about the presence of bleeding.

Assessing for teeth clenching or grinding is not related to this particular observation.

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Correct Answer is A

Explanation

The nurse should prepare the mother for a sweat-chloride test to screen for cystic fibrosis (CF). A sweat- chloride test measures the amount of chloride in the sweat and is used to diagnose CF. CF is a genetic disorder that can cause the body to produce thick, sticky mucus that can clog the lungs and pancreas. One of the symptoms of CF is salty-tasting skin due to an increased amount of salt in the sweat. The other options (B, C, and D) are not standard diagnostic tests for screening for CF.

A. Mumps. B. Chickenpox. C. Sore throat. D. Inﬂuenza.

Correct Answer is C

Explanation

Acute rheumatic fever is a serious inﬂammatory condition that can develop after a streptococcal infection, particularly if the infection is not treated or resolved properly. The most common initial symptom of acute rheumatic fever is a sore throat, which is usually accompanied by a fever and swollen lymph nodes.

While mumps, chickenpox, and inﬂuenza are all infectious diseases, they are not directly linked to the development of acute rheumatic fever. However, a recent or untreated streptococcal infection (such as strep throat) can lead to the development of acute rheumatic fever.

Therefore, when obtaining a health history from a child with a diagnosis of acute rheumatic fever, it is most significant to inquire about recent or untreated sore throat, as this is the most likely cause of the condition.

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While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A mother brings her 2-month-old to the well-baby clinic. She states that when she kisses her baby, the infant's skin tastes salty. The nurse should prepare the mother for what standard diagnostic test to screen for cystic fibrosis (CF)?

Correct Answer is A

Explanation

A 7-year-old child is admited to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant?

Correct Answer is C

Explanation

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While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes.

Which assessment should the nurse implement?