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A nurse is caring for a toddler who has intussusception. Which of the following manifestations should the nurse expect?
- A. Drooling
- B. Increased appetite
- C. Mucus in stools
- D. Jaundice
Correct Answer: C
Rationale: Drooling - Drooling is not typically associated with intussusception. Intussusception is a condition where one portion of the intestine telescopes into another, leading to bowel obstruction and subsequent symptoms such as abdominal pain, vomiting, and 'currant jelly' stools. Increased appetite - Increased appetite is unlikely in a toddler with intussusception. Instead, affected toddlers may experience symptoms such as abdominal pain, vomiting, and lethargy, which can lead to decreased appetite. Mucus in stools - Mucus in stools is a characteristic finding in intussusception. As the telescoping of the intestine causes irritation and inflammation, mucus may be passed in the stool along with blood and, in some cases, a characteristic 'currant jelly' appearance. Jaundice - Jaundice is not a typical manifestation of intussusception. It may be present in conditions affecting the liver or bile ducts, such as biliary atresia or obstructive jaundice, but it is not a direct symptom of intussusception.
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A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?
- A. Place the child in a side-lying position.
- B. Restrain the child's arms.
- C. Elevate the child's legs on a pillow.
- D. Insert a padded tongue blade into the child's mouth.
Correct Answer: A
Rationale: Place the child in a side-lying position. This is the correct action to take during a seizure to prevent aspiration and maintain an open airway. Placing the child in a side-lying position helps to prevent choking or aspiration if vomiting occurs and allows saliva or other fluids to drain out of the mouth instead of being inhaled into the lungs. Restrain the child's arms. Restraining the child's arms is not recommended during a seizure. It can potentially cause injury to the child or the person trying to restrain them. It may also exacerbate muscle spasms and increase the risk of injury during the seizure. Elevate the child's legs on a pillow. Elevating the child's legs on a pillow is not necessary during a seizure and is not a recommended intervention. It does not address the immediate needs of the child during a seizure, such as maintaining an open airway and preventing injury. Insert a padded tongue blade into the child's mouth. Inserting anything into the child's mouth during a seizure, including a tongue blade, is strongly discouraged. It can cause injury to the child's teeth, gums, or oral tissues and increase the risk of choking or aspiration. It may also result in the nurse getting bitten during the seizure. Maintaining a clear airway and ensuring the child's safety are the priorities during a seizure, and inserting objects into the mouth can interfere with these goals.
A nurse is caring for a 6-week-old infant admitted to the pediatric unit for evaluation of a suspected pyloric stenosis. Which of the following findings should the nurse expect?
- A. Projectile vomiting
- B. Metabolic acidosis
- C. Effortless regurgitation
- D. Distended abdomen
Correct Answer: A
Rationale: Projectile vomiting is a classic symptom of pyloric stenosis in infants. It typically occurs within 30 minutes of feeding and is forceful, often projecting several feet away from the infant. This occurs due to the obstruction at the pyloric sphincter, leading to the stomach forcefully emptying its contents. Metabolic acidosis is not a typical finding associated with pyloric stenosis. Pyloric stenosis leads to vomiting, which can result in dehydration and electrolyte imbalances, but it typically does not cause metabolic acidosis directly. Effortless regurgitation is not a characteristic finding of pyloric stenosis. In pyloric stenosis, vomiting is forceful and projectile, rather than a passive regurgitation of stomach contents. A distended abdomen can be a finding in pyloric stenosis. The obstruction at the pyloric sphincter can lead to gastric retention, causing the stomach to become distended over time. However, it's important to note that not all infants with pyloric stenosis will present with a visibly distended abdomen.
A nurse is caring for a 4-year-old child who had an incident of bedwetting during hospitalization. The child's parents expresses concern about the incident. Which of the following responses should the nurse make?
- A. I know this can be embarrassing. I have kids myself so I understand, and it doesn't bother me.
- B. Children who are hospitalized often regress. The toileting skills will return when your child is feeling better.
- C. I will discuss your child's loss of bladder control with the provider.
- D. Why is she wetting the bed in the hospital? She must wet the bed at home.
Correct Answer: B
Rationale: I know this can be embarrassing. I have kids myself so I understand, and it doesn't bother me.' This response acknowledges the child's feelings and reassures the parents that bedwetting is a common occurrence, especially during hospitalization. It also demonstrates empathy by sharing a personal experience. However, it may not address the parents' concerns about their child's bedwetting or provide information on how to manage it. 'Children who are hospitalized often regress. The toileting skills will return when your child is feeling better.' This response provides an explanation for the bedwetting incident, reassuring the parents that it is a common response to hospitalization and will likely resolve once the child feels better. It offers support and normalization of the behavior, which can help alleviate the parents' concerns. 'I will discuss your child's loss of bladder control with the provider.' This response indicates that the nurse will address the issue with the healthcare provider, which is appropriate if further evaluation or intervention is needed. However, it may not directly address the parents' concerns or provide immediate reassurance. 'Why is she wetting the bed in the hospital? She must wet the bed at home.' This response may come across as accusatory or judgmental, which can increase parental anxiety or guilt. It does not provide reassurance or support to the parents and does not address the child's immediate needs.
A nurse is collecting data from a client who has a urinary tract infection. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Hematuria
- B. Urinary frequency
- C. Polyuria
- D. Dependent edema
- E. Dysuria
Correct Answer: A,B,E
Rationale: A. Hematuria: Hematuria, or blood in the urine, is a common finding in urinary tract infections (UTIs). It occurs due to irritation and inflammation of the urinary tract lining, causing small blood vessels to leak blood into the urine. B. Urinary frequency: Urinary frequency, or the need to urinate more often than usual, is a classic symptom of a UTI. It occurs because the infection irritates the bladder lining, leading to a frequent urge to urinate even when the bladder is not full. C. Polyuria: Polyuria, or excessive urination, is not typically associated with uncomplicated urinary tract infections. Instead, UTIs usually cause urinary frequency without necessarily increasing the total volume of urine produced (polyuria). D. Dependent edema: Dependent edema, or swelling in the lower extremities due to fluid accumulation, is not a typical finding in urinary tract infections. UTIs primarily affect the urinary system and do not typically cause system
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.