A nurse is assessing a 1-year-old child. Which of the following disorders should the nurse suspect?
Nephrotic syndrome
Pyloric stenosis
Intussusception
The Correct Answer is C
Choice A Reason:
Nephrotic syndrome is a kidney disorder that causes the body to excrete too much protein in the urine. It is characterized by symptoms such as swelling (edema), particularly around the eyes and in the ankles and feet, foamy urine due to excess protein, and weight gain due to fluid retention. While nephrotic syndrome can occur in children, it is less likely to be the primary suspicion in a 1-year-old presenting with acute symptoms such as severe abdominal pain, vomiting, and bloody stools, which are more indicative of intussusception.
Choice B Reason:
Pyloric stenosis is a condition that affects infants, typically between birth and 6 months of age. It involves the thickening of the pylorus muscle, which blocks food from entering the small intestine. Symptoms include projectile vomiting, dehydration, and weight loss. Although pyloric stenosis is a serious condition that requires medical attention, it is less likely to be suspected in a 1-year-old child compared to intussusception, which is more common in this age group.
Choice C Reason:
Intussusception is a serious condition in which part of the intestine slides into an adjacent part of the intestine, causing a blockage. This condition is most common in children between 3 months and 3 years old56. Symptoms include sudden, severe abdominal pain, vomiting, bloody stools (often described as “currant jelly” stools), and a palpable lump in the abdomen. Given the age of the child and the acute nature of the symptoms, intussusception is the most likely diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Places the infant in a side-lying position
Placing an infant with myelomeningocele in a side-lying position can help prevent pressure on the sac, but it is not the most critical action to indicate effective teaching. The primary concern is to protect the sac from infection and injury, which is best achieved by maintaining a dry dressing over it.
Choice B: Performs range of motion on the infant’s hips
Performing range of motion exercises on the infant’s hips is important for preventing joint contractures and promoting mobility. However, this action does not directly address the immediate need to protect the sac from infection and injury, which is the most critical aspect of care for an infant with myelomeningocele.
Choice C: Maintains a dry dressing over the sac
Maintaining a dry dressing over the sac is crucial for preventing infection and protecting the exposed spinal cord and nerves. This action directly addresses the primary concern in the care of an infant with myelomeningocele, which is to prevent infection and further injury to the exposed neural tissue. Therefore, this choice indicates that the new nurse has effectively understood the most critical aspect of care for these infants.
Choice D: Takes an axillary temperature
Taking an axillary temperature is a standard nursing procedure for monitoring an infant’s temperature. While it is important, it does not specifically address the unique needs of an infant with myelomeningocele. The primary concern remains the protection of the sac, making this action less indicative of effective teaching in this context.
Correct Answer is B
Explanation
Choice A: FACES
The FACES pain scale is typically used for children aged 3 years and older. It involves children pointing to a face that best represents their pain level, ranging from a happy face at “no pain” to a crying face at “worst pain.” Since a 6-month-old infant cannot understand or communicate using this scale, it is not appropriate for this age group.
Choice B: FLACC
The FLACC (Face, Legs, Activity, Cry, Consolability) scale is designed for infants and young children who cannot verbalize their pain. It assesses five criteria: facial expression, leg movement, activity level, cry, and consolability. Each criterion is scored from 0 to 2, with a total score ranging from 0 to 10. This scale is suitable for a 6-month-old infant as it relies on observable behaviors rather than self-reporting.
Choice C: Oucher
The Oucher pain scale is a visual tool that uses photographs of children’s faces showing different levels of pain. It is generally used for children aged 3 to 12 years. Like the FACES scale, it requires the child to identify with the faces, making it unsuitable for a 6-month-old infant who cannot comprehend or communicate in this manner.
Choice D: Visual Analog Scale
The Visual Analog Scale (VAS) is a self-report tool where individuals rate their pain on a continuum, usually a 10 cm line ranging from “no pain” to “worst pain imaginable.” This scale is appropriate for older children and adults who can understand and communicate their pain levels. It is not suitable for infants who cannot provide self-reports.
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