A nurse is assessing an infant who has intussusception.
Which of the following manifestations should the nurse expect?
Polyuria.
Scaphoid abdomen.
Gelatinous red stool.
Generalized edema.
The Correct Answer is C
Choice A rationale
Polyuria, or excessive urination, is not a characteristic symptom of intussusception. Intussusception is a condition where a segment of the intestine telescopes into an adjacent section, leading to a mechanical bowel obstruction. This condition is primarily related to the gastrointestinal system and its symptoms are focused there, not the urinary system.
Choice B rationale
A scaphoid abdomen, which appears sunken or concave, is typically associated with conditions causing a lack of abdominal contents, such as malnutrition or diaphragmatic hernia. In intussusception, a mass is formed by the telescoping bowel, and the resulting edema and obstruction often lead to abdominal distention, not a scaphoid appearance. The abdomen may feel full or tender.
Choice C rationale
Intussusception causes a compromise of blood flow to the intestinal wall, leading to inflammation and necrosis. This results in the sloughing of the intestinal mucosa and bleeding. The combination of mucus and blood in the stool creates a characteristic "currant jelly" or gelatinous red appearance. This classic sign is a direct result of the specific pathophysiological process occurring in the bowel.
Choice D rationale
Generalized edema, which is the accumulation of fluid throughout the body, is not a typical manifestation of intussusception. While localized edema may occur at the site of the telescoping bowel due to vascular compromise, widespread fluid retention is not a hallmark sign. Generalized edema is more commonly seen in conditions like renal failure, liver disease, or heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Sealing non-washable items in a plastic bag for 2 days is insufficient for killing lice and nits. The recommended duration for sealing items is 2 weeks because this timeframe ensures that any remaining nits hatch and the newly hatched lice die from a lack of a human host, as they can only survive for 1 to 2 days without a blood meal. A shorter duration risks re-infestation.
Choice B rationale
Soaking hairbrushes, combs, and similar items in boiling water for at least 5 to 10 minutes is an effective method for killing any lice or nits that may be clinging to them. The high temperature denatures the proteins of the insects and their eggs, leading to their demise. This is a crucial step in preventing re-infestation after treatment of the scalp.
Choice C rationale
Permethrin 1 percent cream rinse is typically applied to the hair and scalp for a specific duration, usually 10 minutes, and then rinsed off. It is not intended for daily use for 5 days. Daily application can lead to scalp irritation and potential systemic absorption, and it is not more effective than a single, properly timed application followed by a repeat treatment in 7 to 9 days to kill newly hatched lice.
Choice D rationale
Washing bed linens and clothing in hot water followed by drying on a hot setting is the correct procedure to kill lice and nits. A cool setting on a dryer would not generate sufficient heat to effectively eliminate the parasites. The high heat of a hot setting is necessary to denature the proteins and desiccate the lice and nits, ensuring they are dead and unable to cause re-infestation.
Correct Answer is C
Explanation
Choice A rationale
Urinalysis findings in acute glomerulonephritis typically reveal a high specific gravity due to concentrated urine resulting from the kidneys' attempt to conserve fluid in the presence of decreased glomerular filtration. Low specific gravity, on the other hand, is a finding more consistent with conditions like diabetes insipidus, chronic renal failure, or overhydration, where the renal tubules have impaired concentrating ability. A specific gravity of 1.010 to 1.030 is considered normal.
Choice B rationale
Acute glomerulonephritis is characterized by increased glomerular capillary permeability, allowing larger molecules like protein to leak into the urine. This results in significant proteinuria, which is a key diagnostic finding. Decreased protein levels in the urine would be considered a normal finding, or a finding in conditions without glomerular damage, and would therefore not be consistent with a diagnosis of acute glomerulonephritis. Normal urine protein is less than 150 mg/24 hours.
Choice C rationale
Red blood cell casts are a definitive microscopic finding in acute glomerulonephritis and are formed when red blood cells aggregate in the renal tubules and are molded into a cylindrical shape by the Tamm-Horsfall protein. Their presence confirms a glomerular origin of the hematuria and is a specific indicator of an active inflammatory process within the glomeruli. This finding is highly specific to glomerulonephritis.
Choice D rationale
The urine pH in acute glomerulonephritis is typically acidic, with a normal range of 4.5 to 8.0. A pH of 8.0 is at the upper end of the normal range and could indicate an alkaline state, which is more commonly associated with conditions like urinary tract infections caused by urease-producing bacteria, or a vegetarian diet, rather than the inflammatory process of acute glomerulonephritis.
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