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Rationale for correct choices

• Inspect the child’s oropharynx: The child has bright red emesis and visible bleeding in the posterior pharynx, which indicates active post-tonsillectomy hemorrhage. Direct visualization helps confirm the bleeding source and severity. Early inspection supports rapid intervention because post-operative tonsillar bleeding can progress quickly and become life-threatening.

• Obtaining a set of vital signs: Active bleeding and vomiting bright red blood require immediate reassessment of vital signs to detect tachycardia, hypotension, or respiratory compromise. Hemoglobin and hematocrit are already low, increasing the child’s risk for hemodynamic instability. Timely vital signs guide urgent decisions about fluid resuscitation and notifying the provider.

Rationale for incorrect choices

• Offer the child a red popsicle: Providing red-colored fluids can mask ongoing bleeding and delay recognition of hemorrhage. The priority is to assess and stabilize the child with known bleeding, not to offer oral intake. This intervention risks obscuring the color of emesis or oral bleeding.

• Place the child in a supine position: Supine positioning increases the risk of aspiration when bleeding or vomiting is present. The child should be maintained upright to allow drainage and airway protection. Supine positioning does not address the current complication and may worsen respiratory safety.

• Encouraging the child to cough and deep breathe: Coughing can dislodge clots and worsen post-tonsillectomy bleeding. The child already has active bright red bleeding, so stimulating airway pressure would increase hemorrhage risk. This intervention is inappropriate in immediate postoperative bleeding scenarios.

• Requesting a prescription for codeine: Codeine is contraindicated in children after tonsillectomy due to risk of respiratory depression from ultra-rapid metabolism. Pain is mild, and bleeding—not pain—is the priority. Requesting codeine does not address the current danger of hemorrhage.

Rationale for correct choices

• Major depressive disorder: The client demonstrates a flat affect, poor hygiene, hopelessness, and verbal statements expressing worthlessness, which strongly indicate major depressive disorder. Their statement about life not being worth living and wishing they were dead reflects severe depressive cognition. Sleep disturbances and social withdrawal also match diagnostic features of depression rather than cognitive or personality disorders.

• Observe the client continuously: The client verbalizes suicidal thoughts and expresses profound hopelessness, making close observation essential for safety. Continuous monitoring reduces the risk of self-harm while ensuring immediate intervention if their condition worsens. The presence of an actively bleeding wound earlier further increases concern for impulsive behavior.

• Ask the client if they have had thoughts of ending their life: Direct inquiry about suicidal thoughts helps the nurse assess the depth, frequency, and intent behind the client’s statements. Exploration of ideation supports development of an appropriate safety plan and therapeutic interventions. Asking directly does not increase suicidal behaviour, it helps identify the level of immediate danger.

• Suicidal ideation: Monitoring suicidal ideation is vital due to the client’s explicit expressions of wanting to die and feeling worthless. Changes in mood or verbal statements can indicate escalating risk requiring prompt intervention. Regular assessment helps the nurse evaluate whether the client is developing a plan or intent. Tracking ideation ensures appropriate treatment and maintains safety.

• Hygiene practices: Poor hygiene is a hallmark symptom of major depressive disorder and reflects impaired self-care capacity. Monitoring hygiene helps gauge the severity of the depressive episode and the client’s functional decline. Improvement or worsening of hygiene can indicate changes in mood or motivation. Observing self-care patterns guides the nurse in planning interventions.

Rationale for incorrect choices

• Dementia: The client is oriented, communicates clearly, and exhibits affective rather than cognitive symptoms, which do not match dementia. Dementia involves progressive memory loss, confusion, and disorientation, none of which appear in the assessment. The rapid onset associated with emotional triggers also differs from dementia’s gradual progression.

• Alcohol withdrawal delirium: The client shows no signs of autonomic hyperactivity such as tremors, tachycardia beyond baseline, diaphoresis, or hallucinations. Although they smell of alcohol, the symptoms reflect mood disturbance rather than withdrawal physiology. Alcohol withdrawal delirium is acute, severe, and typically presents with confusion and agitation, which are absent here.

• Dependent personality disorder: Although the client asks their partner to stay, this is common during crisis and does not indicate chronic dependency patterns. Dependent personality disorder requires long-term behaviors such as difficulty making decisions without approval or fear of abandonment, which are not described. Current behavior reflects emotional distress rather than a personality structure.

• Administer chlordiazepoxide: Chlordiazepoxide is used for alcohol withdrawal, which is not evidenced in this client. Without signs such as tremors, hypertension spikes, or agitation, the medication would not address the presenting issue. Sedation from benzodiazepines could worsen depressive symptoms or impair assessment accuracy.

• Teach assertive behaviors: Assertiveness training is appropriate for long-term therapy but is not suitable during acute crisis. The client is currently expressing suicidal thoughts and hopelessness, requiring safety measures rather than psychosocial skill-building. Attempting to teach behaviors during this emotional state can increase frustration. Stabilization must occur first.

• Determine client’s level of orientation: There are no indications of confusion, disorientation, or cognitive impairment. The client communicates clearly and provides coherent history, suggesting orientation is intact. Orientation assessment would not address the immediate safety risk posed by active suicidal ideation. Priority should remain on direct suicide assessment and monitoring.

• Wandering at night: Night wandering relates to dementia or delirium and does not align with the client’s depressive symptoms. The client’s sleep issues involve insomnia and staying awake watching TV, not ambulation or confusion. Monitoring wandering would not provide insight into their mental health crisis. The risk lies more in self-harm than disorientation.

• Autonomic hyperactivity: No signs such as sweating, tremors, severe tachycardia, or elevated temperature are present. The vital signs are stable, and the client’s presentation lacks the physiological markers of withdrawal delirium. Monitoring autonomic activity would not provide useful information related to depression. Emotional symptoms take diagnostic priority here.

• Fear of separation: Fear of separation is typically associated with dependent or anxious attachment patterns, not major depressive disorder. The client’s request for their partner to stay appears rooted in emotional distress and fear of being alone during crisis rather than a pervasive dependency pattern. Monitoring this would not address the acute suicidal risk.

Rationale for correct choices

• Pneumonia: The child has shallow respirations, diminished breath sounds at the bases, and repeated refusal to use the incentive spirometer, all of which decrease lung expansion. Postoperative abdominal pain further limits deep breathing, increasing atelectasis risk that can progress to pneumonia.

• Shallow breathing: Shallow respirations reduce alveolar ventilation and impair airway clearance, predisposing the child to atelectasis and subsequent pneumonia. Pain from the abdominal incision discourages deep breathing, worsening shallow breathing over time. The diminished breath sounds at the lung bases confirm reduced expansion.

Rationale for incorrect choices

• Wound infection: The abdominal dressing remains dry and intact throughout the shift, with no redness, swelling, or drainage. The child’s temperature is only mildly elevated and does not reflect a pattern typical of surgical site infection. Pain is generalized postoperative discomfort rather than localized wound changes. No wound findings suggest progression toward infection.

• Peritonitis: Although abdominal tenderness is present, this is expected after appendectomy and shows no signs of guarding, rigidity, or rebound tenderness. The child remains alert and interactive, which is inconsistent with systemic peritoneal infection. Vital signs remain stable aside from mild tachycardia that can accompany pain. These findings argue against peritonitis.

• Temperature: The temperature remains below the threshold for concern and is only slightly elevated, which is common postoperatively and not specific to pneumonia. Temperature changes alone do not provide clear evidence for the identified risk. More reliable indicators include respiratory patterns and breath sound changes.

• Bowel sounds: Absent bowel sounds are expected for several hours postoperatively and do not relate to respiratory complications such as pneumonia. This finding reflects postoperative ileus rather than pulmonary risk.