A nurse is collecting data from an infant. Which of the following is a clinical manifestation of pyloric stenosis?
Projectile vomiting after feedings
Absent bowel sounds
Increased sodium level
Golf ball-size mass over the left quadrant
The Correct Answer is A
A. Projectile vomiting after feedings: Projectile vomiting after feedings, especially occurring a short time after feeding, is a classic sign of pyloric stenosis due to obstruction at the pylorus.
B. Absent bowel sounds: Absent bowel sounds may occur in more advanced cases of bowel obstruction but are not specific to pyloric stenosis.
C. Increased sodium level: Increased sodium level is not typically associated with pyloric stenosis.
D. Golf ball-size mass over the left quadrant: A palpable mass in the left quadrant is not a typical finding in pyloric stenosis.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I expect the color of my urine to be amber." Ferrous sulfate does not typically affect the color of urine. This statement indicates a misunderstanding of the medication's effects.
B. "I will expect dark, tarry stools." Ferrous sulfate can cause stools to become dark or black, which is a common and expected side effect due to the iron content. This indicates the client understands a normal side effect of the medication.
C. "I will not get as many infections." Ferrous sulfate is used to treat iron deficiency anemia and does not directly influence the incidence of infections. This indicates a lack of understanding of the medication’s purpose.
D. "I will take extra care to protect against increased bruising." Increased bruising is not associated with ferrous sulfate. This indicates a misunderstanding of the medication's side effects.
Correct Answer is C
Explanation
A. Test the urine for ketones. While testing for ketones can be part of illness management in diabetes, it is not as immediate an action as contacting a healthcare provider when blood glucose levels are very high.
B. Withhold insulin dose if feeling nauseous. Insulin should not be withheld due to nausea. It is important to maintain insulin to control blood glucose levels even when feeling unwell. Adjustments to insulin may be necessary based on blood glucose levels and food intake.
C. Notify the provider if blood glucose levels are over 350 mg/dL. Blood glucose levels over 350 mg/dL are concerning and may indicate the need for medical intervention to prevent complications like diabetic ketoacidosis. The healthcare provider should be notified.
D. Limit fluid intake during meal time. Adequate fluid intake is important, especially when blood glucose levels are high, to help prevent dehydration and facilitate glucose clearance. Limiting fluids is not appropriate.
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