A nurse is assessing a 1-year-old child.
Which of the following disorders should the nurse suspect?
Intussusception.
Wilms tumor.
Pyloric stenosis.
Nephritic syndrome.
The Correct Answer is B
Choice A rationale
Intussusception is a serious condition in which part of the intestine slides into an adjacent part of the intestine. This “telescoping” often blocks food or fluid from passing through.
Intussusception also cuts off the blood supply to the part of the intestine that’s affected. It can lead to a tear in the bowel (perforation), infection and death of bowel tissue.
Choice B rationale
Wilms’ tumor is a rare kidney cancer that primarily affects children. Also known as nephroblastoma, Wilms’ tumor is the most common cancer of the kidneys in children. Wilms’ tumor most often affects children ages 3 to 4 and becomes much less common after age 52.
Choice C rationale
Pyloric stenosis is a condition that affects infants between birth and 6 months of age and causes forceful vomiting that can lead to dehydration. It’s the second most common reason why newborns have surgery. Pyloric stenosis can be fixed with a surgical procedure called pyloromyotomy.
Choice D rationale
Nephrotic syndrome is a kidney disorder that causes your body to excrete too much protein in your urine. Nephrotic syndrome is usually caused by damage to the clusters of small blood vessels in your kidneys that filter waste and excess water from your blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Confusion or disorientation can be a normal part of the dying process. As the body systems start to shut down, changes in mental status, including confusion, can occur.
Choice B rationale
Sundowning is a phenomenon that is typically associated with dementia, particularly Alzheimer’s disease, and is characterized by confusion and agitation that gets worse in the late afternoon and evening. It is not specifically associated with the dying process.
Choice C rationale
While anxiety can occur at any stage of illness, it is not the most appropriate response in this context. The family member is specifically asking about confusion, not anxiety.
Choice D rationale
Needing more rest could be a part of the dying process, but it does not directly address the family member’s concern about confusion.
Correct Answer is B
Explanation
Choice A rationale
The Scale for Assessment of Negative Symptoms (SANS) is a tool used to assess negative symptoms in schizophrenia and is not typically used in the assessment of cognitive disorders.
Choice B rationale
The Mental Status Examination (MSE) is a key part of the clinical assessment process in psychiatric practice. It is a structured way of observing and describing a patient’s current state of mind, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and judgement.
Choice C rationale
The Abnormal Involuntary Movements Scale (AIMS) is a rating scale that measures involuntary movements known as tardive dyskinesia (a side effect of long-term use of antipsychotic drugs). It is not typically used in the assessment of cognitive disorders.
Choice D rationale
The Mini-Mental State Examination (MMSE) is a commonly used test for complaints of memory problems or when a diagnosis of dementia is being considered. However, in this case, the MSE would be a more comprehensive tool.
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