Physiological Integrity Q 13

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A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:

  

     A. Body image disturbance

     B. Impaired verbal communication

     C. Risk for aspiration

     D. Pain

    

    

Correct Answer: C. Risk for aspiration

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Always remember your ABCs (airway, breathing, circulation) when selecting an answer. Place the child prone or side-lying position. Promotes drainage of blood and unswallowed saliva from the mouth that can potentially be aspirated.

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Option A: Does not apply for a child who has undergone a tonsillectomy. Assess for signs and symptoms of inadequate oxygenation. Early signs of hypoxia include confusion, irritability, headaches, pallor, tachycardia, and tachypnea.

Option B: Observe the child for nonverbal indications of pain such as crying, grimacing, irritability. Provides additional information about pain. The child may find discomfort in speaking.

Option D: Although these nursing diagnoses might be appropriate for this child, risk for aspiration should have the highest priority. Apply an ice collar on the neck or encourage the child to eat popsicles. Cold promotes vasoconstriction and decreases swelling that contributes to pain.

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