A client with fibromyalgia asks the nurse to arrange for hospice care to help manage the severe, chronic pain. Which intervention should the nurse provide to address the client's problem?

Rationale for Correct Choices

• Intussusception: This condition is common in young children and is characterized by intermittent, severe abdominal pain, vomiting, and blood-streaked or "currant jelly" stools. The child's posture (knees to chest), pain pattern, and bloody stool strongly point to intussusception.
• Place a nasogastric tube: An NG tube helps decompress the bowel and relieve symptoms such as vomiting and abdominal distension, which are common in intussusception. It also prevents aspiration while awaiting treatment.
• Prepare the child for surgery: If non-surgical reduction (e.g., air enema) fails or the bowel is compromised, surgical intervention is required. Preparing for surgery is appropriate due to the severity of symptoms.
• Abdominal girth: Measuring abdominal girth helps detect increasing distension, which could indicate worsening obstruction, perforation, or edema—serious complications of intussusception.
• Stool color: Stool color should be closely monitored to assess resolution of the obstruction. Return to normal brown stools suggests successful reduction of the intussusception.

Rationale for Incorrect Choices

• Irritable bowel syndrome: IBS is rare in children and does not typically present with vomiting, bloody stool, or acute severe pain. It's a chronic condition with milder, recurring symptoms.
• Acute hepatitis: Hepatitis presents with jaundice, malaise, and abdominal discomfort, not acute, colicky pain, vomiting, or bloody stools. It's also uncommon in this age group without risk factors.
• Gastroesophageal reflux: GERD involves regurgitation or vomiting but not bloody stool or severe abdominal pain. The child’s pain pattern and blood in stool make this unlikely.
• Place the child in Trendelenburg position: This position is not recommended in abdominal emergencies like intussusception, as it can worsen intra-abdominal pressure and discomfort.
• Provide ice chips: The child is NPO (nothing by mouth) due to the risk of surgery and aspiration. Ice chips are contraindicated.
• Administer a glycerin suppository: Constipation is not the issue; glycerin would not resolve intussusception and could worsen the situation or delay definitive treatment.
• Urine output: Although important in general assessment, it is less specific for tracking the resolution of intussusception compared to stool color and abdominal girth.
• Platelet count: Not a primary concern in intussusception unless there’s an unrelated bleeding or clotting disorder.
• Bleeding: Monitoring for active bleeding is not a priority in intussusception unless signs of massive hemorrhage appear, which is rare. Stool monitoring gives more specific clues.

Rationale:
A. Provide support on the unaffected side: Supporting from the unaffected side gives less control if the weak side gives out. Assistance should be on the affected side to better prevent falls and provide stabilization.

B. Hook an arm under the client's left arm: This is unsafe and risks injury to both the client and nurse. It provides poor leverage, may dislocate the shoulder, and does not allow controlled support during ambulation.

C. Use a gait belt standing on affected side: This is the safest technique. Standing on the affected side offers direct support and balance while the gait belt allows secure, ergonomic assistance during movement.

D. Hold the gait belt with palms facing down: Gait belts should be held with palms facing up, which provides a more secure grip and better control if the client loses balance during ambulation.