A nurse is caring for a 6-week-old infant who has pyloric stenosis. Which of the following clinical manifestations should the nurse expect?
Distended neck veins
Rigid abdomen
Projectile vomiting
Red currant jelly stools
The Correct Answer is C
Choice A: Distended neck veins are not a clinical manifestation of pyloric stenosis, which is a condition that causes the narrowing of the pylorus, which is the opening between the stomach and the small intestine. Distended neck veins are a sign of increased venous pressure, which can occur in conditions that affect the right side of the heart or cause fluid overload.
Choice B: Rigid abdomen is not a clinical manifestation of pyloric stenosis, but rather a sign of peritonitis, which is inflammation of the peritoneum, which is the membrane that lines the abdominal cavity. Peritonitis can be caused by infection, perforation, or trauma to any abdominal organ. A rigid abdomen indicates severe pain and inflammation in the abdominal cavity.
Choice C: Projectile vomiting is a clinical manifestation of pyloric stenosis, as it indicates forceful expulsion of stomach contents due to obstruction at the pylorus. Projectile vomiting can occur shortly after feeding and may contain undigested milk or formula. Projectile vomiting can cause dehydration, electrolyte imbalance, or weight loss.
Choice D: Red currant jelly stools are not a clinical manifestation of pyloric stenosis, but rather a sign of intussusception, which is a condition that causes telescoping of one segment of bowel into another. Intussusception can cause obstruction and ischemia of the bowel and lead to bleeding and necrosis. Red currant jelly stools indicate blood and mucus in the stool.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Contact precautions are not necessary for a child who has mumps, as mumps is not transmitted by direct or indirect contact with the infected person or their environment. Contact precautions are used for infections that are spread by contact with skin, wounds, body fluids, or contaminated surfaces.
Choice B: Standard precautions are always used for any patient care, regardless of their diagnosis or infection status. Standard precautions include hand hygiene, use of personal protective equipment (PPE), safe injection practices, and proper disposal of waste and sharps. However, standard precautions alone are not sufficient for a child who has mumps, as mumps are transmitted by respiratory droplets.
Choice C: Airborne precautions are not necessary for a child who has mumps, as mumps are not transmitted by small particles that remain suspended in the air and can be inhaled by others. Airborne precautions are used for infections that are spread by airborne transmission, such as tuberculosis, measles, or chickenpox.
Choice D: Droplet precautions are required for a child who has mumps, as mumps are transmitted by large respiratory droplets that are expelled when the infected person coughs, sneezes, or talks. Droplet precautions include wearing a surgical mask when within 3 feet of the patient, placing the patient in a private room or cohorts with other patients with the same infection, and limiting visitors and staff who are susceptible to the infection.
Correct Answer is D
Explanation
Choice A: Allowing for imaginative play with peers without supervision is not an appropriate intervention for a child who has autism spectrum disorder, as it can cause frustration, anxiety, or isolation for the child. A child who has autism spectrum disorder may have difficulty with social skills, communication, and imagination, which can affect their ability to interact and play with others. The nurse should provide structured and supervised play activities that promote socialization and cooperation.
Choice B: Providing a completely unpredictable schedule that adjusts to the child's interests is not an appropriate intervention for a child who has autism spectrum disorder, as it can cause confusion, stress, or tantrums for the child. A child who has autism spectrum disorder may have difficulty with transitions, changes, and flexibility, which can affect their ability to cope and adapt to different situations. The nurse should provide a consistent and predictable schedule that follows a routine and gives clear expectations.
Choice C: Allowing for adjustment of rules to correlate with the child's behavior is not an appropriate intervention for a child who has autism spectrum disorder, as it can cause inconsistency, insecurity, or manipulation for the child. A child who has autism spectrum disorder may have difficulty understanding and following rules, which can affect their ability to behave and function appropriately. The nurse should provide firm and fair rules that are enforced consistently and respectfully.
Choice D: Establishing a reward system for positive behavior with prizes is an appropriate intervention for a child who has autism spectrum disorder, as it can provide motivation, reinforcement, and feedback for the child. A child who has autism spectrum disorder may have difficulty with learning and performing new skills, which can affect their ability to achieve and succeed. The nurse should provide a reward system that recognizes and rewards positive behavior with tangible or intangible prizes.
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