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When assessing a 3-month-old with Hirschsprung's disease, which finding should the nurse report immediately?
- A. Soft, formed stools.
- B. Abdominal distension.
- C. Regular feeding patterns.
- D. Mild fussiness.
Correct Answer: B
Rationale: Abdominal distension may indicate obstruction, requiring urgent intervention.
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As part of a health education program, the nurse teaches a group of parents CPR. The nurse determines the teaching has been effective when a parent states:
- A. If I am by myself, I should call for help before starting CPR.
- B. I should compress the chest using 2-3 fingers.
- C. I should deliver chest compression at a rate of 100 per minute.
- D. If I can't get the breaths to make the chest rise, I should administer abdominal thrusts.
Correct Answer: A
Rationale: Calling for help before starting CPR when alone ensures timely emergency response, which is critical for improving outcomes.
A parent asks which nutrient deficiency is common in children with celiac disease. The nurse should respond:
- A. Vitamin C.
- B. Iron.
- C. Vitamin A.
- D. Magnesium.
Correct Answer: B
Rationale: Iron deficiency is common in celiac disease due to malabsorption in the small intestine. Other deficiencies (e.g., vitamin D, B vitamins) may occur, but iron is most frequent.
After emphasizing to an adolescent with renal failure the importance of maintaining a positive self-concept, which of the following behaviors by the adolescent should the nurse identify as an indicator that the plan is working?
- A. Reports of headaches, abdominal pain, and nausea.
- B. Insistence on making diet choices even if the foods chosen are restricted.
- C. Verbalization of plans to quit all after-school activities when returning home.
- D. Demonstration of desire to do the dressing changes and take care of the medications.
Correct Answer: D
Rationale: Self-care indicates positive adjustment.
Eight hours ago, an infant with Hirschsprung's disease had surgery to create a colostomy. Which of the following findings should alert the nurse to notify the physician immediately?
- A. A 3-cm increase in abdominal circumference.
- B. Periods of occasional fussiness.
- C. Absence of bowel sounds since surgery.
- D. Evidence of the infant's returning appetite.
Correct Answer: A
Rationale: A 3-cm increase in abdominal circumference may indicate complications like obstruction or bleeding.
The toddler with nephrotic syndrome exhibits generalized edema. Which of the following measures should the nurse institute for this child with a nursing diagnosis of Impaired skin integrity related to edema?
- A. Ambulate every shift while awake.
- B. Apply lotion on opposing skin surfaces.
- C. Apply powder to skinfolds.
- D. Separate opposing skin surfaces with soft cloth.
Correct Answer: D
Rationale: Prevent skin breakdown.