Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings is a manifestation of hemorrhage?
A. increased pain
Increased pain: Increased pain is a common and expected finding after a tonsillectomy. The surgical removal of tonsils creates wounds in the throat, which can cause discomfort and pain during the healing process. However, increased pain alone is not a specific manifestation of hemorrhage. Hemorrhage would be indicated by other signs, such as drooling, frequent swallowing, or vomiting blood.
B. Frequent swallowing
This can indicate that the child is swallowing blood, which is a common sign of bleeding at the surgical site. Children might not always show obvious signs of bleeding in the mouth, so frequent swallowing can be a subtle but critical indicator of hemorrhage.
C. Poor fluid intake
Poor fluid intake: Poor fluid intake is a common concern after a tonsillectomy due to postoperative pain and discomfort in the throat. The child may be reluctant to drink or eat initially because of their sore throat. However, poor fluid intake alone is not an indicative sign of hemorrhage. Hemorrhage would present with other symptoms, such as drooling, frequent swallowing, or vomiting blood.
D. Drooling
While drooling can occur due to discomfort, pain, or difficulty swallowing, it is not as specific or immediate a sign of hemorrhage as frequent swallowing.
This question is an excerpt from Nurse Dive's nursing test bank - SIMMONS U BSN PEDIATRICS PROCTORED EXAM. Take the full exam now
Full Explanation
Correct answer: B
A. Increased pain: Increased pain is a common and expected finding after a tonsillectomy. The surgical removal of tonsils creates wounds in the throat, which can cause discomfort and pain during the healing process. However, increased pain alone is not a specific manifestation of hemorrhage. Hemorrhage would be indicated by other signs, such as drooling, frequent swallowing, or vomiting blood.
B. Frequent swallowing: This can indicate that the child is swallowing blood, which is a common sign of bleeding at the surgical site. Children might not always show obvious signs of bleeding in the mouth, so frequent swallowing can be a subtle but critical indicator of hemorrhage.
C. Poor fluid intake: Poor fluid intake is a common concern after a tonsillectomy due to postoperative pain and discomfort in the throat. The child may be reluctant to drink or eat initially because of their sore throat. However, poor fluid intake alone is not an indicative sign of hemorrhage. Hemorrhage would present with other symptoms, such as drooling, frequent swallowing, or vomiting blood.
D. Drooling: While drooling can occur due to discomfort, pain, or difficulty swallowing, it is not as specific or immediate a sign of hemorrhage as frequent swallowing.
Similar Questions
A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority?
A. Respiratory rate 20/min
B. Abdominal pain rated 4 on a scale of 0 to 10
C. Heart rate 72/min
D. Blood pressure 92/50 mm Hg
The nurse's priority assessment finding in an adolescent who experienced blunt trauma to the abdomen is low blood pressure (hypotension). Hypotension could indicate significant internal bleeding or hemorrhage, which is a life-threatening condition and requires immediate attention. The decreased blood pressure may be a sign of shock, and prompt intervention is needed to stabilize the client's condition and prevent further deterioration. While all the other findings (respiratory rate, abdominal pain, and heart rate) are important and should be assessed and monitored, blood pressure is the most critical in this situation due to its potential association with severe internal injuries and the risk of hypovolemic shock.
Full Explanation
The nurse's priority assessment finding in an adolescent who experienced blunt trauma to the abdomen is low blood pressure (hypotension). Hypotension could indicate significant internal bleeding or hemorrhage, which is a life-threatening condition and requires immediate attention. The decreased blood pressure may be a sign of shock, and prompt intervention is needed to stabilize the client's condition and prevent further deterioration.
While all the other findings (respiratory rate, abdominal pain, and heart rate) are important and should be assessed and monitored, blood pressure is the most critical in this situation due to its potential association with severe internal injuries and the risk of hypovolemic shock.
A nurse is teaching the mother of a 5-year-old child who has cystic fibrosis about pancreatic enzymes. The nurse should understand that further teaching is necessary when the mother states which of the following?
A. "I will put the enzyme crystals in his applesauce.
This is a correct statement. Pancreatic enzymes are often available in a powdered form, and they can be mixed with soft foods like applesauce to make it easier for the child to take them.
B. "The enzymes probably won't cause many adverse effects."
This is a correct statement. Pancreatic enzymes are generally safe and well-tolerated. Adverse effects are uncommon and typically mild, such as abdominal discomfort or diarrhea.
C. "The enzymes help him digest fat.
This is a correct statement. Pancreatic enzymes help the child digest fats, proteins, and carbohydrates, which are essential for proper nutrition and growth.
D. "I will give my son the enzymes between meals.
In cystic fibrosis, the pancreas does not secrete enough digestive enzymes, leading to malabsorption of nutrients, especially fats. To help with digestion, pancreatic enzymes are prescribed to be taken with meals and snacks. These enzymes should be given just before or with each meal or snack to aid in the breakdown and absorption of nutrients.
Full Explanation
In cystic fibrosis, the pancreas does not secrete enough digestive enzymes, leading to malabsorption of nutrients, especially fats. To help with digestion, pancreatic enzymes are prescribed to be taken with meals and snacks. These enzymes should be given just before or with each meal or snack to aid in the breakdown and absorption of nutrients.
A nurse is providing discharge teaching about nutrition to the parents of a child who has cystic fibrosis (CF). Which of the following responses by the parents indicates an understanding of the teaching?
A. "We will restrict the amount of salt in our child's food."
"We will restrict the amount of salt in our child's food."Sodium restriction is generally not a focus in CF management unless there are specific indications for it. CF patients may have increased salt losses in sweat, but dietary sodium restriction is not a primary aspect of their care.
B. I will limit my child's fluid intake."
"I will limit my child's fluid intake."Fluid intake is important for children with CF to maintain hydration and prevent dehydration. There is no specific need to limit fluid intake unless there are individualized medical reasons for doing so.
C. "I will prepare low-fat meals with limited protein for my child."
"I will prepare low-fat meals with limited protein for my child."Children with CF often require a high-calorie, high-protein diet to maintain adequate nutrition and growth. Restricting fat and protein intake is not typically recommended, as these nutrients are essential for a child's development and well-being. Instead, pancreatic enzymes are used to aid in the digestion and absorption of fats and other nutrients.
D. "We will give our child pancreatic enzymes with snacks and meals."
Cystic fibrosis (CF) is a genetic disorder that affects the production and function of certain glands, particularly those that produce mucus and sweat. One of the key aspects of CF management is addressing the pancreatic insufficiency that occurs in many individuals with CF. Due to the impairment of the pancreas, children with CF may have difficulty digesting food properly, especially fats. This can lead to malabsorption of nutrients, poor weight gain, and other nutritional deficiencies. Pancreatic enzyme replacement therapy is a crucial part of CF management. Pancreatic enzymes are prescribed to help the child digest and absorb essential nutrients, especially fats. The enzymes are typically given with each meal and snack to aid in the breakdown and absorption of nutrients.
Full Explanation
Cystic fibrosis (CF) is a genetic disorder that affects the production and function of certain glands, particularly those that produce mucus and sweat. One of the key aspects of CF management is addressing the pancreatic insufficiency that occurs in many individuals with CF. Due to the impairment of the pancreas, children with CF may have difficulty digesting food properly, especially fats. This can lead to malabsorption of nutrients, poor weight gain, and other nutritional deficiencies.
Pancreatic enzyme replacement therapy is a crucial part of CF management. Pancreatic enzymes are prescribed to help the child digest and absorb essential nutrients, especially fats. The enzymes are typically given with each meal and snack to aid in the breakdown and absorption of nutrients.
The other options are not correct:
A. "We will restrict the amount of salt in our child's food."
Sodium restriction is generally not a focus in CF management unless there are specific indications for it. CF patients may have increased salt losses in sweat, but dietary sodium restriction is not a primary aspect of their care.
B. "I will limit my child's fluid intake."
Fluid intake is important for children with CF to maintain hydration and prevent dehydration. There is no specific need to limit fluid intake unless there are individualized medical reasons for doing so.
C. "I will prepare low-fat meals with limited protein for my child."
Children with CF often require a high-calorie, high-protein diet to maintain adequate nutrition and growth. Restricting fat and protein intake is not typically recommended, as these nutrients are essential for a child's development and well-being. Instead, pancreatic enzymes are used to aid in the digestion and absorption of fats and other nutrients.