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Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they indicate improvement in the child’s condition. Also, recalling the significance of decerebrate posturing will direct you to the correct option. If you are unfamiliar with the significance of assessment findings in the child with increased intracranial pressure, review this content.Reference: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal-child nursing care (4th ed., 1555). St. Louis: Elsevier.Level of Cognitive Ability: AnalyzingClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/AnalysisContent Area: Child Health – Neurological Awarded 0.0 points out of 1.0 possible points. 86.ID: 383723113An ambulatory care nurse is providing home care instructions to the mother of a child who had a tonsillectomy. The nurse determines that the mother needs further instruction if she indicates that she will: Avoid giving citrus juices to her child
Have her child use a straw to make drinking easier Correct Give acetaminophen (Tylenol) to her child for discomfort Give her child extra fluids to relieve a foul odor from the mouth Rationale: Introduction of a straw, fork, or any other pointed object into the mouth could result in accidental contact with the surgical site and disrupt its integrity. Citrus fruits are avoided because they could irritate the throat. Acetaminophen is used for pain relief. A foul mouth odor is normal and can be relieved by drinking fluids.Test-Taking Strategy: Use the process of elimination, noting the strategic words “needs further instruction,” which indicate a negative event query and the need to select the incorrect statement. Considering the anatomical location of the surgery will direct you to the correct option. Remember, introducing a straw, fork, or any other pointed object into the mouth could result in accidental contact with the surgical site and disrupt its integrity. Review postoperative care after tonsillectomy if you had difficulty with this question.Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 1184). St. Louis: Elsevier.Level of Cognitive Ability: EvaluatingClient Needs: Physiological IntegrityIntegrated Process: Teaching and LearningContent Area: Child Health – Throat and Respiratory Awarded 0.0 points out of 1.0 possible points.