A nurse is caring for an infant who has inadequate motility of a portion of the intestine, resulting in a mechanical obstruction. The nurse should identify this finding as a manifestation of which of the following disorders?
Pyloric stenosis
Hirschsprung's disease
Enterocolitis
Intussusception
The Correct Answer is B
A. Pyloric stenosis involves narrowing of the pylorus, causing vomiting and dehydration, not mechanical obstruction due to motility issues.
B. Hirschsprung's disease is a condition where part of the intestine lacks proper motility due to missing nerve cells, leading to a mechanical obstruction and constipation.
C. Enterocolitis typically involves inflammation and infection of the intestines, not a motility issue.
D. Intussusception is a condition where one part of the intestine telescopes into another, causing an obstruction, but it is not related to motility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pyloric stenosis typically causes projectile vomiting shortly after feedings. After vomiting, the infant may still appear hungry and may want to feed again. This is because the blockage prevents food from entering the small intestine, causing the infant to feel hungry soon after vomiting.
B. One of the classic physical findings of pyloric stenosis is a palpable "olive-shaped" mass in the upper abdomen, which is usually located in the right upper quadrant. This mass is the enlarged pyloric muscle.
C. Jelly-like stools are more characteristic of intussusception, not pyloric stenosis.
D. While the child may show signs of discomfort or irritability due to hunger, severe pain in the abdomen is not a hallmark of pyloric stenosis.
Correct Answer is A
Explanation
A. Pain is a common and distressing symptom in children with otitis media. Assessing and managing the
child’s pain should be a priority.
B. While assessing vision can be important in some conditions, it is not a priority for recurrent otitis media.
C. Assessing lung sounds is important for respiratory assessments but not as relevant for otitis media.
D. Blood pressure assessment is not specifically indicated for otitis media unless there are other concerns.
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