A nurse is caring for a school-age child admitted for suspected Hirschsprung's disease.
Which provider order should the nurse querry
Insert a nasogastric tube for decompression of abdomen.
NPO status and initiate IV fluids.
Monitor abdominal girth every 4 hours.
Administer a large-volume liquid enema.
The Correct Answer is D
Choice A rationale
Inserting a nasogastric tube for decompression of the abdomen is a standard intervention for suspected Hirschsprung's disease, which is characterized by a lack of ganglion cells in a segment of the colon, leading to impaired motility and potential bowel obstruction. Decompression helps relieve abdominal distension and pressure.
Choice B rationale
NPO status and initiating IV fluids are appropriate initial management for a child with suspected Hirschsprung's disease to rest the bowel and maintain hydration and electrolyte balance while further diagnostic tests are performed.
Choice C rationale
Monitoring abdominal girth every 4 hours is essential to assess for increasing abdominal distension, which can indicate worsening obstruction in Hirschsprung's disease. An increasing girth would warrant further investigation and intervention.
Choice D rationale
Administering a large-volume liquid enema is contraindicated in suspected Hirschsprung's disease. Due to the aganglionic segment's impaired motility, the enema fluid may not be expelled and could lead to fluid overload or bowel perforation. Diagnostic enemas using contrast are performed under controlled conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Pain is a common symptom in superficial and partial-thickness burns where nerve endings are still intact. While pain indicates tissue damage, the absence of pain in a burn area can signify deeper and more severe injury where nerve endings have been destroyed.
Choice B rationale
No pain with pale, leathery skin is a characteristic finding of a full-thickness (third-degree) burn. The destruction of nerve endings eliminates pain sensation, and the skin appears dry, leathery, and may be white, charred, or translucent due to damage to all skin layers and underlying tissue.
Choice C rationale
Mild erythema, or redness of the skin, is characteristic of a superficial (first-degree) burn, such as a sunburn. These burns involve only the epidermis and are typically painful and without blisters.
Choice D rationale
Blister formation is a hallmark of partial-thickness (second-degree) burns, which involve the epidermis and part of the dermis. These burns are typically painful and moist.
Correct Answer is C
Explanation
Choice A rationale
Corn is naturally gluten-free and is generally safe for individuals with celiac disease to consume. Celiac disease is an autoimmune disorder triggered by gluten, a protein found in wheat, barley, and rye.
Choice B rationale
Rice, in all its forms (white, brown, wild), is naturally gluten-free and is a staple grain in the diet of individuals with celiac disease. It does not contain the gliadin protein that triggers the autoimmune response in celiac disease.
Choice C rationale
Wheat contains gluten, specifically the gliadin fraction, which triggers the damaging autoimmune response in the small intestine of individuals with celiac disease. Therefore, all products containing wheat, including bread, pasta, and many processed foods, must be strictly avoided.
Choice D rationale
Oats are naturally gluten-free; however, they are often processed in facilities that also handle wheat, barley, or rye, leading to cross-contamination. While certified gluten-free oats are available, regular oats may not be safe for individuals with celiac disease due to this risk of contamination.
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