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A nurse is caring for a child who has Hirschsprung disease. Which of the following findings should the nurse expect?
- A. Ridged abdomen
- B. Ribbonlike, foul-smelling stools
- C. Projectile vomiting
- D. Chronic hunger
Correct Answer: B
Rationale: Ridged abdomen - This finding is not typically associated with Hirschsprung disease. Instead, the abdomen may appear distended or bloated due to the accumulation of stool in the colon. Ribbonlike, foul-smelling stools - This is a characteristic finding in Hirschsprung disease. Because the affected portion of the colon lacks nerve cells (ganglion cells) responsible for peristalsis, stool movement is impaired, leading to the passage of narrow, ribbonlike stools. These stools may also have a foul odor due to bacterial overgrowth in the affected area. Projectile vomiting - Projectile vomiting is not a common finding in Hirschsprung disease. It is more commonly associated with conditions such as pyloric stenosis or gastroesophageal reflux. Chronic hunger - Chronic hunger is not a typical finding in Hirschsprung disease. Instead, affected infants may experience feeding difficulties, constipation, and failure to thrive due to the obstruction of stool in the colon. They may also exhibit symptoms such as abdominal distention, vomiting, and refusal to feed.
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A nurse is assisting with the care of a client who has partial-thickness and full-thickness burns to his upper torso and face. Which of the following actions should the nurse take to prevent infection?
- A. Place new linen on the client's bed every other day.
- B. Change gloves between sites when providing wound care to multiple wounds.
- C. Change the dressing on infected wounds first.
- D. Monitor vital signs every 4 hr.
Correct Answer: B
Rationale: Place new linen on the client's bed every other day: While changing linen regularly is important for maintaining cleanliness and preventing infection, waiting every other day may not be sufficient for a client with burns, especially if there is wound drainage or soiling. Linens should be changed more frequently, ideally daily or as needed, to ensure cleanliness and prevent the spread of infection. Change gloves between sites when providing wound care to multiple wounds: This is a correct action. Changing gloves between sites when providing wound care helps prevent the spread of infection from one wound to another. It reduces the risk of cross-contamination and helps maintain a sterile environment during wound care procedures. Change the dressing on infected wounds first: This is incorrect. Dressings on infected wounds should be changed promptly to prevent the spread of infection. However, changing the dressing on infected wounds first may lead to contamination of other wound sites if proper precautions are not taken. It's important to follow proper infection control procedures, including changing gloves between wound sites and using aseptic technique. Monitor vital signs every 4 hr: Monitoring vital signs is important for assessing the client's overall condition, but it is not directly related to preventing infection. Vital signs may indicate signs of infection, such as fever or increased heart rate, but they do not prevent infection on their own. Other measures, such as wound care and infection control practices, are more directly related to preventing infection in clients with burns.
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?
- A. Monitor the client's hemoglobin level
- B. Restrain the client's extremities
- C. Place the client in a prone position
- D. Record the time and length of the seizure
Correct Answer: D
Rationale: Monitor the client's hemoglobin level: Monitoring the client's hemoglobin level is not relevant during a seizure. Seizures typically do not directly affect hemoglobin levels, so this action is not appropriate. Restrain the client's extremities: Restraint is generally not recommended during a seizure unless absolutely necessary for the safety of the client or others. Restraint can potentially cause injury to the client and increase agitation during the seizure. Place the client in a prone position: Placing the client in a prone (face-down) position during a seizure is not recommended. This position may increase the risk of airway obstruction and compromise the client's ability to breathe effectively. Record the time and length of the seizure: This is the correct answer. During a seizure, the nurse should prioritize ensuring the safety of the client and others. After ensuring safety, the nurse should document important details about the seizure, including the time it began and ended, as well as any observed symptoms or behaviors. This documentation can provide valuable information for the client's healthcare team and help guide future treatment decisions.
A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?
- A. Move the child into a side-lying position.
- B. Place a pillow under the child's head.
- C. Time the seizure.
- D. Remove the child's eyeglasses.
Correct Answer: A
Rationale: Move the child into a side-lying position: This action is crucial during a seizure with vomiting to prevent aspiration. Placing the child on their side helps ensure that any vomit can easily exit the mouth and reduces the risk of choking or aspiration into the lungs. Place a pillow under the child's head: While providing comfort is important, it is not the priority during a seizure with vomiting. Placing a pillow under the child's head might elevate the head slightly, but it doesn't address the risk of aspiration, which is the primary concern. Time the seizure: Timing the seizure is important for documentation and to monitor the duration of the seizure. However, it is not the priority during the active phase of the seizure, especially when vomiting is occurring. Remove the child's eyeglasses: Removing the child's eyeglasses is not a priority during a seizure with vomiting. While it's important to prevent injury, particularly to the eyes, during a seizure, the immediate concern is addressing the risk of aspiration caused by vomiting.
A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?
- A. Change to cloth diapers until the skin is healed.
- B. Use a moisturizer to wipe urine from the skin.
- C. Apply a light layer of talcum powder with each diaper change.
- D. Expose the excoriated area to hot air frequently.
Correct Answer: B
Rationale: While some parents may prefer cloth diapers, they can retain moisture and irritants. Disposable diapers with good absorbency are often preferred in managing diaper dermatitis. Using a gentle moisturizer to clean the skin can help protect the infant's skin and maintain its barrier function, especially in cases of diaper dermatitis. Moisturizers help soothe and heal the affected area by providing hydration and protection. Talcum powder is not recommended due to the risk of inhalation, which can cause respiratory issues. Additionally, powders can clump and worsen skin irritation. Exposing the skin to hot air can dry out the skin and worsen irritation. It's better to allow the area to air-dry naturally or use a cool blow dryer on a low setting.
The nurse is instructing a mother of a 1-year-old child with strabismus about the treatment options. Which statement by the mother would indicate the need for further teaching?
- A. “There are a few causes of this condition and they tell me my child has crossed eyes because of a muscle imbalance.
- B. I will have my child wear an eye patch over the good eye to help strengthen the weak eye.
- C. My child will outgrow this by the time he is 2 years old and be able to see just fine.
- D. If this eye patch does not work I know we will have to do surgery to correct my child's crossed eyes.
Correct Answer: C
Rationale: There are a few causes of this condition and they tell me my child has crossed eyes because of a muscle imbalance.': This statement demonstrates the mother's comprehension of the cause of strabismus, which can indeed result from a muscle imbalance affecting the alignment of the eyes. Understanding the cause is essential for the mother to grasp the rationale behind treatment interventions. 'I will have my child wear an eye patch over the good eye to help strengthen the weak eye.': Patching the stronger eye is a common treatment approach for strabismus to encourage the weaker eye to become stronger and improve alignment. The mother's statement indicates her awareness of this treatment modality. 'My child will outgrow this by the time he is 2 years old and be able to see just fine.': While some cases of strabismus may improve as a child grows, not all cases resolve spontaneously. This statement suggests the mother's belief in the possibility of spontaneous resolution, which may be accurate in some instances but not guaranteed for all cases of strabismus. 'If this eye patch does not work I know we will have to do surgery to correct my child's crossed eyes.': Surgery is indeed an option for correcting strabismus, especially if conservative measures like patching do not yield satisfactory results. The mother's understanding of this potential treatment escalation reflects her grasp of the condition's management plan.