The nurse is caring for a boy with probable intussusception. While waiting for a radiologist-guided pneumonia to visualize and correct the intussusception, the child passes a currant jelly-like stool.
Which nursing action is the most appropriate?
Measure the abdominal girth.
Notify the practitioner as this is not a typical finding.
Document as an expected finding and plan to move forward with the procedure.
Auscultate for bowel sounds.
The Correct Answer is C
Choice A reason:
Measuring the abdominal girth is a useful assessment tool in cases of suspected abdominal distension or fluid accumulation. However, in the context of intussusception, the passage of a currant jelly-like stool is a more critical indicator of the condition. While measuring abdominal girth can provide additional information, it is not the most appropriate immediate action in this scenario.
Choice B reason:
Notifying the practitioner as this is not a typical finding is incorrect because the passage of currant jelly-like stool is a classic symptom of intussusception. This stool appearance results from a mixture of mucus and blood due to the telescoping of the intestine, which compromises blood flow and causes ischemia. Therefore, this finding should be documented as expected rather than considered atypical.
Choice C reason:
Documenting the passage of currant jelly-like stool as an expected finding and planning to move forward with the procedure is the most appropriate action. This stool appearance is a hallmark sign of intussusception, indicating that the condition is present and needs to be addressed promptly. The radiologist-guided pneumoenema is a diagnostic and therapeutic procedure that can help resolve the intussusception by using air pressure to unfold the telescoped segment of the intestine. Therefore, documenting this finding and proceeding with the planned intervention is crucial.
Choice D reason:
Auscultating for bowel sounds is a standard nursing assessment technique to evaluate gastrointestinal function. However, in the context of intussusception, the passage of currant jelly-like stool is a more definitive indicator of the condition. While auscultating for bowel sounds can provide additional information about bowel activity, it is not the most appropriate immediate action in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A reason:
Facial edema is a common clinical manifestation of nephrotic syndrome in children. This occurs due to the retention of fluid in the tissues, which is a result of the kidneys leaking protein into the urine (proteinuria). The loss of protein reduces the oncotic pressure in the blood vessels, leading to fluid accumulation in the interstitial spaces, particularly noticeable around the eyes and face.
Choice B Reason:
Cloudy smoky brown-colored urine is not typically associated with nephrotic syndrome. This symptom is more indicative of hematuria, which is the presence of blood in the urine. Hematuria is more commonly seen in conditions such as glomerulonephritis rather than nephrotic syndrome.
Choice C Reason:
Weight loss is not a characteristic symptom of nephrotic syndrome. In fact, children with nephrotic syndrome often experience weight gain due to fluid retention. The accumulation of fluid in the body can lead to an increase in weight, rather than a loss.
Choice D Reason:
Frothy appearing urine is a hallmark sign of nephrotic syndrome. The frothiness is due to the high levels of protein being excreted in the urine (proteinuria). When protein is present in the urine, it can cause the urine to appear foamy or frothy.
Correct Answer is C
Explanation
Choice A reason:
A diet consisting of low-fat, low-carbohydrate foods is not specifically recommended for managing severe edema associated with acute glomerulonephritis. While a balanced diet is important, the primary dietary focus should be on reducing sodium intake to prevent fluid retention and manage edema. Therefore, this choice is not the most appropriate recommendation.
Choice B reason:
Decreasing the number of calories in the child’s diet is not a primary recommendation for managing severe edema associated with acute glomerulonephritis. The focus should be on reducing sodium intake rather than calorie restriction. Adequate nutrition is essential for the child’s overall health and recovery1. Therefore, this choice is not the most appropriate recommendation.
Choice C reason:
Avoiding adding salt to the child’s food is a key recommendation for managing severe edema associated with acute glomerulonephritis. Sodium can lead to water retention, which can worsen edema and increase blood pressure. A low-sodium diet helps to reduce fluid retention and manage the symptoms of glomerulonephritis. This is the most appropriate dietary recommendation for managing severe edema in this condition.
Choice D reason:
Increasing the amount of protein in the child’s diet is not recommended for managing severe edema associated with acute glomerulonephritis1. In fact, protein intake may need to be monitored and possibly restricted to prevent the buildup of waste products in the blood1. The primary dietary focus should be on reducing sodium intake to manage edema. Therefore, this choice is not the most appropriate recommendation.
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