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What assessment(s) would lead a nurse to suspect Hirschsprung's disease in a 1-month-old infant?
- A. Ribbon-like stools
- B. Fever
- C. Failure to thrive
- D. Vomiting
- E. Diminished peristalsis
Correct Answer: A,B,C,D,E
Rationale: Ribbon-like stools, fever, failure to thrive, vomiting, and diminished peristalsis are all indicative of Hirschsprung's disease due to intestinal obstruction.
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What would the nurse expect the parents to report?
- A. Diarrhea
- B. Projectile vomiting
- C. Poor appetite
- D. Constipation
Correct Answer: B
Rationale: Projectile vomiting is a hallmark symptom of pyloric stenosis due to obstruction at the pyloric sphincter.
What description of a child's stool characteristic leads the nurse to suspect intussusception?
- A. Currant jelly
- B. Black and tarry
- C. Green liquid
- D. Greasy and foul-smelling
Correct Answer: A
Rationale: Currant jelly stools, consisting of blood and mucus, are indicative of intussusception due to intestinal obstruction.
Which assessment finding indicates ineffectiveness of treatment?
- A. Weight loss of 4 ounces
- B. Dry mucous membranes
- C. Decreased skin turgor
- D. Depressed fontanelle
Correct Answer: A
Rationale: Weight loss in an infant with gastroenteritis indicates ongoing dehydration, reflecting ineffective treatment.
What does the nurse suspect based on this information?
- A. Pinworms
- B. Giardiasis
- C. Ringworm
- D. Roundworm
Correct Answer: A
Rationale: Anal itching and scratching are characteristic symptoms of pinworm infection.
What will be the nurse's priority goal of the infant's care?
- A. Prevent fluid and electrolyte imbalance.
- B. Prevent nutritional deficiency.
- C. Prevent skin breakdown.
- D. Prevent malabsorption.
Correct Answer: A
Rationale: Preventing fluid and electrolyte imbalance is the priority in acute gastroenteritis to avoid life-threatening complications.