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.

Answer and Explanation

The Correct Answer is []

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.

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Free Nursing Study Resources

Correct Answer is ["A","E"]

Explanation

Rationale:

A. Separate fluids from meals: Fluids should be consumed at least 30 minutes before or after meals to prevent gastric overdistention and dumping syndrome, which are common after bariatric surgery.

B. Plan meals to include rice porridge: Rice porridge is high in simple carbohydrates, which can cause dumping syndrome and rapid gastric emptying. It is not ideal post-surgery.

C. Eliminate acidic food choices: Acidic foods like citrus or tomatoes may cause discomfort, but they are not universally contraindicated. Tolerance varies by individual, so elimination is not routinely necessary.

D. Offer more bread and cheese: Bread can form a sticky bolus that’s hard to swallow post-op, and cheese is high in fat. Both can cause discomfort or intolerance early in recovery.

E. Provide small frequent meals: After bariatric surgery, the stomach’s capacity is reduced, so clients need to eat small, frequent meals to meet nutritional needs and prevent nausea or vomiting.

A. Assess for breath with a fruity odor. B. Titrate an insulin infusion to maintain a low serum glucose level. C. Monitor for elevated temperature and administer PRN antipyretics. D. Monitor serum electrolyte levels and report any abnormal values. E. Maintain large bore IV patency for aggressive fluid resuscitation.

Correct Answer is ["B","D","E"]

Explanation

Rationale:
A. Assess for breath with a fruity odor: This is more indicative of diabetic ketoacidosis (DKA), not HHS. HHS does not usually produce ketones or fruity-smelling breath, so it is not a priority assessment for this condition.

B. Titrate an insulin infusion to maintain a low serum glucose level: Maintaining glucose control through insulin infusion is critical in preventing HHS, as the syndrome is driven by severe hyperglycemia without ketosis.

C. Monitor for elevated temperature and administer PRN antipyretics: While fever management is important for burn care, it does not directly prevent HHS, which is primarily a result of fluid imbalance and hyperglycemia.

D. Monitor serum electrolyte levels and report any abnormal values: Electrolyte disturbances are common in HHS due to dehydration and osmotic diuresis. Prompt correction is essential to prevent complications.

E. Maintain large bore IV patency for aggressive fluid resuscitation: Massive fluid loss from burns and hyperglycemia requires aggressive IV fluid replacement to prevent dehydration and hemoconcentration, both of which contribute to HHS.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which dietary intervention(s) should the nurse include in the plan of care for a client who had bariatric surgery? Select all that apply.

Correct Answer is ["A","E"]

Explanation

A client who has type 2 diabetes mellitus is admitted to the intensive care unit with third degree burns over 20% of the body. To decrease the client's risk of developing hyperosmolar hyperglycemic syndrome (HHS), which intervention(s) should the nurse implement? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

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