A nurse is assessing an infant who has intussusception.
Which of the following findings should the nurse expect?
Sausage-shaped abdominal mass.
Increased urinary output.
Constipation.
Board-like abdomen.
The Correct Answer is A
Choice A rationale:
A sausage-shaped abdominal mass is a classic sign of intussusception, a condition where one segment of the intestine telescopes into another, causing obstruction. This is a medical emergency that requires prompt intervention.
Choice B rationale:
Increased urinary output is not a characteristic finding of intussusception. Instead, the child may present with signs of dehydration due to vomiting, diarrhea, and decreased oral intake caused by the obstruction.
Choice C rationale:
Constipation is a symptom that can be associated with various gastrointestinal disorders but is not specific to intussusception. In intussusception, the child typically experiences severe abdominal pain, vomiting, and the classic sausage-shaped abdominal mass.
Choice D rationale:
A board-like abdomen can occur in conditions such as peritonitis, but it is not a typical finding in intussusception. The presence of a sausage-shaped abdominal mass is the hallmark sign of intussusception.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Placing the child on a clear liquid diet for 24 hours following the arterial cardiac catheterization procedure is not necessary. The procedure does not typically require dietary restrictions. However, the healthcare provider may provide specific pre-procedure dietary instructions if needed, but it's not a standard practice.
Choice B rationale:
Instructing the child that they will be on bed rest for 2 days after the procedure is not accurate. While the child may need to rest after the procedure, the duration of bed rest is typically much shorter than 2 days. It's important to provide accurate information to the child to reduce anxiety and promote understanding.
Choice C rationale:
Explaining to the child that they will need to keep their leg straight for 8 hours following the procedure is important and accurate information. Arterial cardiac catheterization often involves the insertion of a catheter through an artery in the leg, and keeping the leg straight helps prevent complications at the insertion site. This information is essential for the child to follow post-procedure instructions correctly.
Choice D rationale:
Telling the child that their dressing will be removed 12 hours after the procedure is not accurate. Dressing removal timing may vary depending on the healthcare provider's protocol, but it's not typically done immediately after the procedure. Providing inaccurate information may lead to confusion and anxiety for the child.
Correct Answer is A
Explanation
Choice A rationale:
Varicella (chickenpox) is highly contagious and spreads through the air via respiratory droplets. Initiating airborne precautions, such as wearing masks and isolating the patient in a negative pressure room, helps prevent the spread of the virus to other patients and healthcare workers.
Choice B rationale:
Providing a warm blanket is a comfort measure and does not address the contagious nature of varicella. While keeping the child comfortable is important, preventing the spread of the infection to others is a higher priority.
Choice C rationale:
Koplik spots are small, white spots with blue or red centers that can appear on the oral mucosa in individuals with measles. Varicella does not cause Koplik spots; this finding is specific to measles. Therefore, assessing for Koplik spots is not relevant in the context of varicella.
Choice D rationale:
Administering aspirin to a child with varicella is contraindicated due to the risk of Reye's syndrome, a potentially fatal condition characterized by acute brain and liver damage. Acetaminophen is the preferred antipyretic for managing fever in children with varicella.
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