A nurse is caring for a 5-year-old child following a tonsillectomy and adenoidectomy. Which of the following findings should the nurse identify as an indication of hemorrhage?
Continuous swallowing.
Blood pressure 95/56 mm Hg.
Heart rate 54/min.
Flushing of the face.
The Correct Answer is A
Choice A rationale
Continuous swallowing can be an indication of hemorrhage following a tonsillectomy and adenoidectomy. This is because the child may be swallowing blood that is coming from the surgical site.
Choice B rationale
Blood pressure of 95/56 mm Hg is within the normal range for a 5-year-old child and does not specifically indicate hemorrhage.
Choice C rationale
A heart rate of 54/min is lower than the normal range for a 5-year-old child and may indicate bradycardia, but it is not a specific sign of hemorrhage.
Choice D rationale
Flushing of the face is not a specific sign of hemorrhage. It may indicate other conditions but is not typically associated with bleeding following a tonsillectomy and adenoidectomy.
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Correct Answer is B
Explanation
Choice A rationale
Assisting the adolescent to ambulate 12 hours following surgery is not recommended. Early ambulation is important, but 12 hours post-surgery is too soon and can lead to complications such as increased pain and risk of injury.
Choice B rationale
Ensuring two nurses logroll the adolescent every 2 hours is crucial. Logrolling helps maintain spinal alignment and prevents complications such as pressure ulcers and respiratory issues.
Choice C rationale
Maintaining the head of the bed at a 30° angle is not appropriate immediately post-surgery as it can increase pressure on the surgical site and compromise spinal alignment.
Choice D rationale
Offering sips of water 4 hours following surgery is not recommended. Postoperative patients are usually kept NPO (nothing by mouth) for a certain period to prevent aspiration and other complications.
Correct Answer is A
Explanation
Choice A rationale
The FLACC scale (Face, Legs, Activity, Cry, Consolability) is designed to assess pain in children who are unable to communicate their pain verbally, including those who are cognitively impaired. It evaluates five categories: facial expression, leg movement, activity, cry, and consolability, each scored from 0 to 2, with a total score ranging from 0 to 1012.
Choice B rationale
The FACES pain scale is a self-report tool that uses facial expressions to help children aged 3 and older communicate their pain level. It is not suitable for toddlers who are cognitively impaired and unable to self-report.
Choice C rationale
The Visual Analog Scale (VAS) is a unidimensional measure of pain intensity, typically used in older children and adults who can understand and mark their pain level on a continuum. It is not appropriate for toddlers who are cognitively impaired.
Choice D rationale
The CRIES scale is used to assess pain in neonates and infants, particularly postoperatively. It evaluates crying, oxygen requirement, increased vital signs, facial expression, and sleeplessness. It is not designed for toddlers.