Exhibits

Review H and P, nurse's notes, and prescriptions.

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

Rationale for Correct Choices

• Intussusception: This condition is common in young children and is characterized by intermittent, severe abdominal pain, vomiting, and blood-streaked or "currant jelly" stools. The child's posture (knees to chest), pain pattern, and bloody stool strongly point to intussusception.
• Place a nasogastric tube: An NG tube helps decompress the bowel and relieve symptoms such as vomiting and abdominal distension, which are common in intussusception. It also prevents aspiration while awaiting treatment.
• Prepare the child for surgery: If non-surgical reduction (e.g., air enema) fails or the bowel is compromised, surgical intervention is required. Preparing for surgery is appropriate due to the severity of symptoms.
• Abdominal girth: Measuring abdominal girth helps detect increasing distension, which could indicate worsening obstruction, perforation, or edema—serious complications of intussusception.
• Stool color: Stool color should be closely monitored to assess resolution of the obstruction. Return to normal brown stools suggests successful reduction of the intussusception.

Rationale for Incorrect Choices

• Irritable bowel syndrome: IBS is rare in children and does not typically present with vomiting, bloody stool, or acute severe pain. It's a chronic condition with milder, recurring symptoms.
• Acute hepatitis: Hepatitis presents with jaundice, malaise, and abdominal discomfort, not acute, colicky pain, vomiting, or bloody stools. It's also uncommon in this age group without risk factors.
• Gastroesophageal reflux: GERD involves regurgitation or vomiting but not bloody stool or severe abdominal pain. The child’s pain pattern and blood in stool make this unlikely.
• Place the child in Trendelenburg position: This position is not recommended in abdominal emergencies like intussusception, as it can worsen intra-abdominal pressure and discomfort.
• Provide ice chips: The child is NPO (nothing by mouth) due to the risk of surgery and aspiration. Ice chips are contraindicated.
• Administer a glycerin suppository: Constipation is not the issue; glycerin would not resolve intussusception and could worsen the situation or delay definitive treatment.
• Urine output: Although important in general assessment, it is less specific for tracking the resolution of intussusception compared to stool color and abdominal girth.
• Platelet count: Not a primary concern in intussusception unless there’s an unrelated bleeding or clotting disorder.
• Bleeding: Monitoring for active bleeding is not a priority in intussusception unless signs of massive hemorrhage appear, which is rare. Stool monitoring gives more specific clues.