A nurse is caring for an 18-month-old infant.

Exhibits

The nurse has completed the child's admission assessment.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential condition- Intussusception

Intussusception is a condition where one part of the intestine folds into another part, causing an obstruction. It is common in infants and toddlers and typically presents with the following signs- Severe abdominal pain, which causes the child to pull their knees to their chest (classic sign of colicky abdominal pain), red, jelly-like stools (which indicate the presence of blood and mucus in the stool) and palpable mass in the right upper quadrant (which could be the telescoping portion of the bowel).

Actions to Take

Place child on NPO status:

The child should be placed on nothing by mouth (NPO) status to prepare for potential procedures, such as an enema or surgery. This prevents aspiration during any intervention and ensures the bowel is not further irritated by food or liquid intake.

Prepare child for an air enema:

Air enema is a non-invasive treatment for intussusception. It is often used to reduce the telescoping bowel by using air under fluoroscopic guidance. This treatment can resolve the condition in many cases without the need for surgery. The nurse must ensure the child is properly prepared for this procedure (e.g., ensuring the child is NPO, monitoring vitals, and explaining the procedure to the family).

Parameters to Monitor

Stool patterns:

Monitoring the stool patterns is essential to assess the progress and severity of intussusception. The presence of red, jelly-like stools (blood and mucus) is characteristic of intussusception, and any changes in stool appearance can help evaluate the effectiveness of treatment. The nurse should monitor if the stool pattern changes after the air enema or surgical intervention.

Abdominal pain:

Abdominal pain is a hallmark symptom of intussusception, and the nurse should continually assess the child's pain level. The child may experience intermittent, severe cramp-like pain due to the bowel obstruction. Monitoring and managing the pain effectively is crucial for patient comfort and well-being.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Speech and communication abilities are important, but physical safety must come first to prevent accidents or injuries.
B. Safety measures are the highest priority, as children with cognitive impairments may have physical or developmental limitations that increase the risk of falls, accidents, or other harm.
C. Cognitive development and educational needs are important but should be addressed after ensuring
the child’s physical safety.

D. Social and emotional well-being are essential aspects of care, but the immediate focus should be on preventing harm.

A. Trisomy 21 B. Fragile X C. Turners Syndrome D. Williams Syndrome

Correct Answer is B

Explanation

A. Trisomy 21, or Down syndrome, typically presents with features like intellectual disability, a flat facial profile, upward slanting eyes, and a small mouth. The elongated facial structure and ear protrusion are not characteristic of this condition.
B. Fragile X syndrome is associated with developmental delays, autistic behaviors, and distinct physical features such as a long face, large ears, and a prominent jaw. These characteristics are consistent with the child’s presentation.
C. Turner’s syndrome primarily affects females and is characterized by short stature, webbed neck, and gonadal dysgenesis, but it does not typically involve autistic behaviors or elongated facial features.
D. Williams syndrome involves a distinct set of features including a broad forehead, short nose, and full lips. It is not primarily associated with elongated facial features and ear protrusion.

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Actions to Take

Parameters to Monitor

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child with known cognitive impairment. Which of the following is the nurse’s highest priority in the assessment of a child with cognitive impairment?

Correct Answer is B

Explanation

A nurse is assessing a 3-year-old child with autistic behaviors, an elongated facial structure, and protrusion of the ears. The nurse suspects that the child may have which of the following syndromes?

Correct Answer is B

Explanation

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