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A nurse is caring for a 4-year-old pediatric client who has an inguinal hernia. Which of the following statements should the nurse make when the parents ask for clarification about the inguinal hernia?

An inguinal hernia occurs when digestive fluids leak from the bowel, causing swelling that results in a bulge in the groin.

An inguinal hernia occurs when a viral infection weakens the intestine, allowing the bowel to herniate into the groin.

An inguinal hernia occurs when a part of the bowel or fatty tissue slips through a weak spot in the abdominal cavity near the groin.

An inguinal hernia occurs when an accumulation of excess gas in the abdominal cavity results in a bulge in the groin.

Answer and Explanation

The Correct Answer is C

A. An inguinal hernia occurs when digestive fluids leak from the bowel, causing swelling that results in a bulge in the groin is incorrect. An inguinal hernia involves a protrusion of bowel or fatty tissue through a weakness in the abdominal wall, not digestive fluids leaking from the bowel.

B. An inguinal hernia occurs when a viral infection weakens the intestine, allowing the bowel to herniate into the groin is incorrect. Inguinal hernias are congenital or result from increased intra-abdominal pressure, not caused by viral infections.

C. An inguinal hernia occurs when a part of the bowel or fatty tissue slips through a weak spot in the abdominal cavity near the groin is correct. Inguinal hernias occur when tissue, usually part of the intestine or fatty tissue, pushes through a weak area in the abdominal wall near the groin. This condition is common in infants and children.

D. An inguinal hernia occurs when an accumulation of excess gas in the abdominal cavity results in a bulge in the groin is incorrect. While excess gas can cause bloating or discomfort, it is not responsible for the development of an inguinal hernia. The bulge is caused by the protrusion of tissue through a weakness in the abdominal wall.

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Correct Answer is C

Explanation

A. Administer antipyretic therapy is appropriate to help reduce fever, but it is not the first priority. The child’s vital signs indicate a high fever and signs of possible meningitis, and intervention to prevent further complications or the spread of infection should take precedence.

B. Place the child in a lateral Sims position is unnecessary in this case. A lateral Sims position is typically used to prevent aspiration during vomiting, but it is not the priority for this child. The focus should be on infection control and stabilizing the child’s condition.

C. Place the child on droplet precautions is the correct priority. The child is showing signs of possible bacterial meningitis, which is a highly contagious infection. Droplet precautions are necessary to prevent transmission of the infection to other individuals.

D. Reduce all environmental stimuli may be helpful for a child with a neurological condition, but it is not the first priority in this case. The priority is preventing the spread of infection while further stabilizing the child’s condition.

A. Urine specific gravity 1.015 B. Respiratory rate 24/min C. Heart rate 130/min D. Capillary refill greater than 3 seconds

Correct Answer is A

Explanation

A. Urine specific gravity 1.015 is correct. A specific gravity of 1.015 indicates good hydration status and that the child is effectively retaining fluids after oral rehydration therapy. Normal urine specific gravity ranges from 1.010 to 1.020.

B. Respiratory rate 24/min is not directly related to hydration status and does not necessarily indicate that rehydration therapy has been effective. It is a normal rate for a 3-year-old child, but respiratory rate alone isn't an indicator of fluid balance.

C. Heart rate 130/min is elevated for a 3-year-old child and may indicate dehydration or other stressors, suggesting that oral rehydration therapy has not been completely effective. A normal heart rate for this age is typically 80-120 beats per minute.

D. Capillary refill greater than 3 seconds is a sign of dehydration and poor perfusion, indicating that the oral rehydration therapy has not been effective in restoring hydration. Normal capillary refill time is less than 2 seconds.

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A nurse is caring for a 4-year-old pediatric client who has an inguinal hernia. Which of the following statements should the nurse make when the parents ask for clarification about the inguinal hernia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is caring for a 3-year-old child who was admitted with acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective?

Correct Answer is A

Explanation

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