The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the parent to seek health care for the infant?
Diarrhea
Regurgitation of feedings
Projectile vomiting
Foul-smelling ribbon-like stools
The Correct Answer is D
A. Diarrhea
Explanation: Diarrhea is not a typical sign of Hirschsprung's disease. Instead, the condition is associated with constipation due to the obstructed passage of stool.
B. Regurgitation of feedings
Explanation: Regurgitation of feedings is not a characteristic sign of Hirschsprung's disease. It may be seen in other gastrointestinal conditions, but not specifically in this disorder.
C. Projectile vomiting
Explanation: Projectile vomiting is not a typical sign of Hirschsprung's disease. It may be associated with conditions such as pyloric stenosis, but it is not a characteristic feature of Hirschsprung's disease.
D. Foul-smelling ribbon-like stools
Explanation:
Hirschsprung's disease is a congenital condition characterized by the absence of ganglion cells in the rectum and a portion of the colon. The lack of ganglion cells results in functional obstruction, causing stool to accumulate in the affected area. One of the hallmark signs is the presence of foul-smelling, ribbon-like stools, often described as "fecal pellets" or "pellets" due to the obstructed passage of stool.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Crayons and a coloring book:
Incorrect: Crayons and coloring books may not be appropriate for a 12-month-old, as they may pose a choking hazard. Additionally, they might require more direct contact, which may not be ideal under contact precautions.
B. Modeling clay:
Incorrect: Modeling clay may also pose a choking hazard for a toddler. Moreover, it can be messy and may not be suitable for use in a hospital room with contact precautions.
C. Hanging crib toys.
Correct Answer: Hanging crib toys can provide visual and tactile stimulation for the toddler without the need for direct contact. These toys can be attached to the crib, allowing the child to engage with them safely.
D. Large building blocks:
Incorrect: While large building blocks can be suitable for a toddler's developmental needs, they may not be the best option in a confined hospital room under contact precautions. The child's access to and handling of the blocks may be limited in this setting.
Correct Answer is D
Explanation
A. "Carry a water bottle with me because I drink a lot of water."
Explanation: Staying hydrated is crucial, especially for individuals with paralysis who may be prone to urinary issues. Carrying a water bottle is a good practice to maintain adequate hydration.
B. "Use a suppository every night to have a bowel movement."
Explanation: Using a suppository for regular bowel movements is a positive self-care behavior. It helps manage bowel care, which is important for individuals with paralysis.
C. "I do wheelchair exercises while watching TV."
Explanation: Engaging in wheelchair exercises to maintain mobility is a positive self-care behavior. It helps prevent complications related to being sedentary, such as muscle atrophy.
D. "I only need to catheterize myself twice every day."
Explanation: This statement may indicate a need for further teaching. Individuals with paralysis, especially due to conditions like spina bifida, often have neurogenic bladder dysfunction. They typically require more frequent catheterization, potentially every 4-6 hours, to ensure adequate bladder emptying and reduce the risk of complications like urinary tract infections (UTIs) or bladder infections.
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