Reposting Tonsilectomy question...

[smstar1996]

Hello, Student here. This test question is driving me crazy. I prevuosly posted this question, but reposting d/t gave wrong info in one of the answers. Question; 10 yr old pt comes up on floor following a tonsilectomy. What would be the first thing the nurse would address?

A. dark brown emesis

B. falls asleep during assessment

In my textbook it clearly states that dark brown emesis is a normal finding here. I chose B d/t how can you asume the pt fell asleep, couldn't this be a change in level of conscisness possibly from trauma from surgery? I would think that you you first further assess to make sure that that this pt is just sleeping. However, the correct answer from my teacher was A. Don't understand why it would not be B. Your thaughts?

[Daytonite, BSN, RN]

But yeah if I was in nursing school I wouldnt like how it was worded either. I think they should give you more info in the question.......

The question is worded fine. It involves critical thinking and reading the stem of the question carefully. Students have to learn how to read these questions. The information on the sticky I posted has that kind of helpful information on it. The NCLEX is loaded with questions just like this. Students have to understand the nursing process and problem solving or they are going to have all kinds of trouble answering these kinds of questions. They are designed to distract people who are not paying attention.

[icyounurse, BSN, RN]

Ha, I keep adding stuff:)

Sorry I couldnt just put it all in one post, but just wanted to add that you could think of it like the ABC's, and if your post op tonsils patient vomits and either aspirates or starts bleeding out at the site, thats an AIRWAY issue, so it would be addressed first.

I guess since I spent a year in a half in recovery and was so used to seeing patients fall asleep during assessment, its easy for me to say. I know to a nursing student this seems like it might be abnormal, but it rarely is after surgery actually, especially in a healthy child who had a tonsillectomy.

[Daytonite, BSN, RN]

here's a question just posted on the nursing student assistance forum:

• https://allnurses.com/forums/f205/help-me-reason-through-question-336683.html - help me reason through a question

[icyounurse, BSN, RN]

The question is worded fine. It involves critical thinking and reading the stem of the question carefully. Students have to learn how to read these questions. The information on the sticky I posted has that kind of helpful information on it. The NCLEX is loaded with questions just like this. Students have to understand the nursing process and problem solving or they are going to have all kinds of trouble answering these kinds of questions. They are designed to distract people who are not paying attention.

Yeah but when I was in nursing school (and I know things may have changed some) they really threw that whole "change in LOC is the first sign of a severe neurological issue and very serious and must be addressed right away" thing out there, so actually I can see how this might be confusing. Change in LOC was the answer to alot of questions. But not so in this instance obviously. I agree that learning how to answer these questions is imperative, but they can be confusing to students and sometimes even seasoned nurses. I could have told you the answer right away from experience, but it may have confused me some in school too, so I can relate.

But of course I am sure the OP is aware that alot of questions on NCLEX are confusing too, thats why when you miss a confusing question (and whether or not it was confusing to you, it was to the OP) its good to have the rationale for something so you dont make the same mistake twice. Just trying to be helpful.

[smstar1996]

I understand 100% about the emesis. The point I've been trying to make is, how do you know for sure that the pt merely fell asleep during your assessment and not nothing more serious as ina change in LOC d/t possible trauma from surgery if you don't futher investigate this. And now after reading some of the test taking strategies that Daytonight posted, now I'm even more convinced b/c Koplins clarifies you can not implement before assessing. Assessment is always #1 it states. I think I'm way over tired right now. I thank you for your rational, it makes sense, and your the nurse not me.............................but I still believe LOC should be addressed first b/c decreased LOC can lead to aspiration of emesis:zzzzz?????

Right, but what INTERVENTION does being sleepy with anesthesia on board really require immediately in this instance??As long as they wake up and respond appropriately and have a patent aiway and good vitals, this isnt unusual in these cases. Post op tonsils kids will sleep all day long, and you WANT them to.

If a tonsillectomy starts vomiting dark emesis on the other hand you can bet I would be RUNNING to get some nausea medication stat. They can mess up the surgery site, think of the pressure from vomiting where you have your tonsils removed, and if they start bleeding out because you didnt control the vomiting its a vERY big deal and they have to be rushed back to surgery........

[Daytonite, BSN, RN]

the question is very clear. . .

10 yr old pt comes up on floor following a tonsilectomy. what would be the first thing the nurse would

address

?

a. dark brown emesis

b. falls asleep during assessment

here are the first two tiers of maslow's heirarchy of needs:

1. physiological needs (in the following order)
   • the need for oxygen and to breathe [the brain gets top priority for oxygen, then the oxgenation of the heart followed by oxygenation of the lung tissue itself, breathing problems come next, then heart and circulation problems--this is based upon how fast these organs die or fail based upon the lack of oxygen and their function.]
     
   • the need for food and water
     
   • the need to eliminate and dispose of bodily wastes
     
   • the need to control body temperature
     
   • the need to move
     
   • the need for rest
     
   • the need for comfort

[*]safety and security needs (in the following order)

• safety from physiological threat
  
• safety from psychological threat
  
• protection
  
• continuity
  
• stability
  
• lack of danger

where would you place each of those two answer choices on the maslow hierarchy as they are presented in the question?

[Daytonite, BSN, RN]

i understand 100% about the emesis. the point i've been trying to make is, how do you know for sure that the pt merely fell asleep during your assessment and not nothing more serious as ina change in loc d/t possible trauma from surgery if you don't futher investigate this. and now after reading some of the test taking strategies that daytonight posted, now i'm even more convinced b/c koplins clarifies you can not implement before assessing. assessment is always #1 it states. i think i'm way over tired right now. i thank you for your rational, it makes sense, and your the nurse not me.............................but i still believe loc should be addressed first b/c decreased loc can lead to aspiration of emesis:zzzzz?????

read the stem of the problem. it says what would be the first thing the nurse would address? not what would be the first thing the nurse would assess? emesis is going to cause the patient to rupture the sutures and quite possibly aspirate and suffocate. falling asleep indicates that the patient can and has been aroused.

i'm sorry you find this :zzzzz. i'm trying to help you.

[smstar1996]

thankyou for all help in trying to rationalize this for me and will def visit your posted links. so basicaly the pt suddenly falls asleep during assesment could not actualy indicate a possible change in loc d/t possible trauma from surgery which could then lead to aspiration of emesis is not a possibility? and address is "to do something about", well isn't assessing loc addressing a potential problem? again thankyou for your help:bow:.

the question is very clear. . .

10 yr old pt comes up on floor following a tonsilectomy. what would be the first thing the nurse would

address

?

a. dark brown emesis

b. falls asleep during assessment

here are the first two tiers of maslow's heirarchy of needs:

1. physiological needs (in the following order)
   • the need for oxygen and to breathe [the brain gets top priority for oxygen, then the oxgenation of the heart followed by oxygenation of the lung tissue itself, breathing problems come next, then heart and circulation problems--this is based upon how fast these organs die or fail based upon the lack of oxygen and their function.]
     
   • the need for food and water
     
   • the need to eliminate and dispose of bodily wastes
     
   • the need to control body temperature
     
   • the need to move
     
   • the need for rest
     
   • the need for comfort

[*]safety and security needs (in the following order)

• safety from physiological threat
  
• safety from psychological threat
  
• protection
  
• continuity
  
• stability
  
• lack of danger

where would you place each of those two answer choices on the maslow hierarchy as they are presented in the question?

[Daytonite, BSN, RN]

so basicaly the pt suddenly falls asleep during assesment could not actualy indicate a possible change in loc d/t possible trauma from surgery which could then lead to aspiration of emesis is not a possibility?

look up the effects of anesthesia. you are merging two answer choices into one. you can't do that. that's how the writers of these questions trip you up. they do it deliberately to see who is using rational thinking and reading carefully. an answer choice does not contribute to the given information in the stem of the question and is only an answer choice.

and address is "to do something about", well isn't assessing loc addressing a potential problem?

yes, but emesis is a potentially bigger problem. sleepiness from anesthesia is expected and nothing else indicates it is damaging at the moment. emesis has consequences and it needs to be put under control asap.

[icyounurse, BSN, RN]

Thankyou for all help in trying to rationalize this for me and will def visit your posted links. So basicaly the pt suddenly falls asleep during assesment could not actualy indicate a possible change in LOC d/t possible trauma from surgery which could then lead to aspiration of emesis is not a possibility? And address is "to do something about", well isn't assessing LOC addressing a potential problem? Again thankyou for your help:bow:.

You are overthinking it, which is a common problem for many in nursing school. Its actually very simple. Maslow's is a great way to answer these questions as daytonite pointed out. I always did ABC's myself for many NCLEX questions too.

1st is always A=Airway, then B=breathing, and then look to C=circulation.

Is change of LOC an immediate threat to the airway, breathing, or circulation??

No its not.

Is vomiting in a post op tonsillectomy an immediate threat to the airway??

You betcha.

So while it is not wrong persay to choose to further assess LOC, it is not the most immediate thing that needs to be done. On NCLEX you will find that more than one anwser is correct, but the trick is you have to pick the most correct. And the emesis is simply the most correct of the 2 in this case.

Does this help any??

[bimmersbabe]

I have not been on in a few days and saw this repost - I had read the first also. Daytonite and icyounurse are correct and have outlined it perfectly. I have fought tooth and nail over some questions while in school (just graduated in May). However, the truth is the stem of the question is the key.

Address - look at that as Active INTERVENTION - not assessment. They have completed the assessment and came up with problems A,B,C,D Which of THOSE choices is the highest priority - back to ABC's and Maslow

Some spitting of dark brown is normal - emesis is a whole other thing to me - and you would not want that!

I really, really hope this helps. The other thing as a student you need to learn is to let somethings go, and I don't mean that ugly. I know it is frustrating. However, this question will not matter 5 years down the road and there are so many stressful situations in nursing school - I don't want you to end up a basket case!!:heartbeat

[squirtle]

I think Daytonite and Icyounurse have given perfect information as to why answer A is correct as well. You mentioned in the beginning that you might be reading too much into the question- but I think it is the answer you are reading too much in to. You asked how you could assume that the pt just fell asleep during the assessment, but that is exactly what the answer choice states. It doesn't say something like "pt's head falls back on pillow during assessment", if it did then you would be making an assumption as to whether or not the pt fell asleep. It clearly says the pt is sleeping.

In addition, as other have stated, you must "address" emesis. If not for the bleeding issue that would be suggested with dark brown emesis, it would be for the airway issue of aspiration.

When answering questions it helps me to decide from the beginning if I need to assess or implement and then go with ABC's and then on to Maslow. In your mind if you begin to think "but what if..." you are beginning to read too much in to it.