A nurse in an acute care facility is caring for a toddler.

Exhibits

For each assessment finding below, click to specify if the assessment finding is consistent with Crohn's disease, appendicitis, or intussusception. Each finding may support more than 1 disease process.

Pain rating

Vomiting

Stool

Temperature

Abdominal findings

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B,C"},"C":{"answers":"A,C"},"D":{"answers":"B"},"E":{"answers":"C"}}

Pain rating: Severe, intermittent abdominal pain where the child draws their knees to the chest and then returns to normal behavior is a classic symptom of intussusception. Neither Crohn’s disease nor appendicitis typically presents with this pattern, appendicitis pain is usually constant and worsening, while Crohn’s pain is chronic and non-episodic.
Vomiting: Vomiting in intussusception is common and often non-bilious in early stages, aligning with the child's light-colored emesis. Vomiting also occurs in appendicitis, especially in the early stages. However, it is not a prominent or early symptom of Crohn’s disease unless obstruction is present.
Stool: The presence of blood and mucus in the stool ("currant jelly stool") is strongly associated with intussusception and may also occur in Crohn’s disease during flares due to colonic inflammation. Appendicitis does not typically cause bloody or mucoid stools, making this finding inconsistent with that diagnosis.
Temperature: A temperature of 37.4°C is within normal limits, appendicitis however may present with low grade fever. The absence of fever at this time limits its diagnostic value in this case.
Abdominal findings: A distended abdomen with hypoactive bowel sounds and a palpable sausage-shaped mass in the right upper quadrant is highly indicative of intussusception. These findings are not characteristic of appendicitis, which usually involves RLQ pain, or Crohn’s, which rarely presents with a discrete palpable mass.

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Correct Answer is B

Explanation

A. The client calls the office multiple times per day to speak with their provider. This behavior may indicate anxiety or dependence, but it does not reflect rationalization, which involves making excuses to justify behavior.
B. The client states, "I only act this way because my partner makes me so angry." This is a clear example of rationalization, where the client is attempting to justify unacceptable behavior by blaming it on someone else rather than taking personal responsibility.
C. The client does not listen to the nurse during a discussion about their diagnosis. This may indicate denial or avoidance, not rationalization. The client may be overwhelmed and unwilling to accept the diagnosis.
D. The client reports that they get upset with their family members for "no apparent reason." This may suggest emotional dysregulation or projection, but it lacks the clear element of excuse-making that defines rationalization.

A. Place the booster seat where there is an air bag in the vehicle. B. Avoid using the lap shoulder belt when the child is in a booster seat. C. Use a no-back booster seat if the vehicle seat has a headrest. D. Keep the booster seat rear-facing until the child weighs at least 16 kg (35.3 lb

Correct Answer is C

Explanation

A. Place the booster seat where there is an air bag in the vehicle. Booster seats should never be placed in front of an active air bag, especially in the front seat. Air bags can cause serious injury or death to young children in the event of deployment.
B. Avoid using the lap shoulder belt when the child is in a booster seat. A lap-shoulder belt is required for proper use of a booster seat. The shoulder belt helps distribute force across the child’s chest and shoulders in a crash. Using only a lap belt increases the risk of serious abdominal and spinal injuries.
C. Use a no-back booster seat if the vehicle seat has a headrest. This is correct and safe. A no-back booster is appropriate as long as the vehicle seat has a high back or headrest that provides support for the child’s neck and head, ensuring proper positioning of the seat belt.
D. Keep the booster seat rear-facing until the child weighs at least 16 kg (35.3 lb). Booster seats are designed for forward-facing children who have outgrown a forward-facing harness seat, typically around 4 years of age and 40 pounds. Rear-facing seats are used prior to booster seats, for infants and toddlers, not for booster seat-age children.

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A nurse in an acute care facility is caring for a toddler. Exhibits For each assessment finding below, click to specify if the assessment finding is consistent with Crohn's disease, appendicitis, or intussusception. Each finding may support more than 1 disease process.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new diagnosis of chronic stress. Which of the following findings should the nurse recognize as being a manifestation of rationalization?

Correct Answer is B

Explanation

A nurse is teaching the parents of a toddler about booster seat safety. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?

A nurse in a mental health facility is caring for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse take?

A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?

A nurse is assisting with food selection for a client who follows kosher dietary traditions. Which of the following food choices should the nurse include on the client's food tray?

A nurse is caring for a client who has a Clostridium difficile infection. Which of the following actions should the nurse take? (Select all that apply)

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply)

A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record?

A nurse is admitting a client who is to undergo paracentesis for removal of ascitic fluid. Which of the following actions should the nurse take?

A nurse in an acute care facility is caring for a toddler.

Exhibits

For each assessment finding below, click to specify if the assessment finding is consistent with Crohn's disease, appendicitis, or intussusception. Each finding may support more than 1 disease process.