A nurse is caring for an 18-month-old infant.
The Correct Answer is []
Condition: Intussusception
Actions to Take:
- Place child on NPO status - The child should not receive oral intake to prevent aspiration and to prepare for potential surgical intervention or a procedure like an air enema, which is commonly used to treat intussusception.
- Prepare child for air enema - An air enema is the preferred non-surgical treatment for intussusception. It may help reduce the telescoping of the bowel and restore normal bowel function.
Parameters to Monitor:
- Stool patterns - Red, jelly-like stools are a key characteristic of intussusception, which is caused by the telescoping of the intestines. Monitoring stool patterns helps assess the progression and resolution of the condition.
- Abdominal pain - The child is already experiencing severe abdominal pain, often associated with intussusception. Ongoing monitoring of pain will help gauge the effectiveness of treatment and any changes in the condition.
Rationale
Intussusception is a condition where one part of the intestine slides into another, leading to obstruction. It is a common cause of abdominal pain and is characterized by red, jelly-like stools due to the presence of blood and mucus. The child's symptoms, including abdominal pain, crying, and the palpable mass, strongly suggest this condition.
Air enema is a non-invasive treatment that can reduce the telescoped segment of the intestine, often resolving the issue without the need for surgery.
Stool patterns and abdominal pain are both critical indicators of the condition's progress, and careful monitoring will help guide further interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Diabetes mellitus is not directly linked to excessive milk consumption. While a poor diet can contribute to other health issues, it is not typically associated with diabetes in toddlers.
B. Obesity could result from excessive milk intake if it leads to an imbalance in caloric intake versus expenditure, but iron deficiency anemia is a more likely concern due to the lack of solid food intake.
C. Iron deficiency anemia is a concern in toddlers who consume large amounts of milk because milk is low in iron. Additionally, milk can interfere with iron absorption and may cause the child to avoid ironrich foods.
D. Rickets is typically related to vitamin D deficiency, not directly to excessive milk consumption.
Although vitamin D is necessary for calcium absorption, it is not typically impacted by milk alone.
Correct Answer is D
Explanation
A. Monitoring for fluid volume excess is not appropriate for Addison's disease, where there is usually fluid volume deficit due to low aldosterone levels.
B. Hyperglycemia is not commonly associated with Addison's disease; instead, hypoglycemia can occur.
C. A low-sodium diet is inappropriate for children with Addison's disease. They typically need extra salt due to a deficiency in aldosterone.
D. Cortisol replacement therapy is essential in managing Addison's disease. Parents should be educated on how to administer and adjust the dosage in response to illness or stress.
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