A nurse is caring for a newborn who may have pyloric stenosis. Which of the following manifestations should the nurse expect?
Presence of Dance sign
Projectile vomiting
Always seems full
Excessive weight gain
The Correct Answer is B
A. Presence of Dance sign. Dance sign (an empty right lower quadrant on palpation) is associated with intussusception, not pyloric stenosis. Pyloric stenosis is characterized by hypertrophy of the pyloric sphincter, leading to gastric outlet obstruction.
B. Projectile vomiting. Forceful, non-bilious projectile vomiting is the hallmark symptom of pyloric stenosis. It occurs due to the narrowing of the pyloric sphincter, preventing stomach contents from passing into the small intestine. Vomiting usually begins around 2 to 6 weeks of age and worsens over time.
C. Always seems full. Infants with pyloric stenosis actually experience hunger and irritability after vomiting because food is not reaching the intestines for digestion and absorption.
D. Excessive weight gain. Instead of gaining weight, infants with pyloric stenosis often experience weight loss or poor weight gain due to repeated vomiting and inadequate nutrient absorption.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Kawasaki disease is an abnormal immune response that only affects the liver." This is incorrect. Kawasaki disease primarily affects the blood vessels, especially the coronary arteries, not just the liver. While liver inflammation can occur, it is not the main concern.
B. "Kawasaki disease is an abnormal immune response that causes injury to the body's muscles." This is incorrect. Kawasaki disease is a vasculitis (inflammation of blood vessels), not a muscle disorder. It mainly affects the heart and blood vessels, potentially leading to aneurysms and long-term cardiac complications.
C. "Kawasaki disease is an abnormal immune response in which the body attacks the skin only." This is incorrect. While skin changes (such as a rash, peeling skin, and red palms/soles) are common symptoms, the primary concern is inflammation of the coronary arteries, which can lead to serious heart complications.
D. "Kawasaki disease is an abnormal immune system response that can weaken the coronary arteries." This is correct. Kawasaki disease triggers inflammation in medium-sized arteries, particularly the coronary arteries, which supply blood to the heart. If untreated, this can lead to coronary artery aneurysms, myocardial infarction, or long-term heart disease.
Correct Answer is B
Explanation
A. Administering the insulin injection quickly to minimize discomfort. Administering an injection quickly may reduce discomfort, but it does not address the emotional and psychological aspects of atraumatic care. The goal is to minimize fear and distress, not just physical pain.
B. Explaining the procedure in simple terms to the client before administering the insulin. Providing a clear, age-appropriate explanation helps reduce anxiety and fosters trust between the child and the nurse. Understanding what to expect allows the child to feel a sense of control, which is a key principle of atraumatic care.
C. Asking the client to look away during the injection to reduce anxiety. While looking away may help some children, it does not promote understanding or involvement in their care. Instead, explaining the procedure allows the child to develop coping strategies and feel more secure.
D. Using a larger needle to ensure accurate insulin delivery. Insulin is administered using a small-gauge needle to minimize pain. A larger needle is unnecessary and could increase discomfort, contradicting the principles of atraumatic care.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
