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 C
Explanation
Choice A reason:
Opioid analgesics are not given as a last resort solely because of the threat of addiction. While the risk of addiction is a concern, opioids are often necessary for managing severe pain, especially in conditions like sickle cell anemia. The American Society of Hematology guidelines emphasize the importance of effective pain management in sickle cell disease, which often includes the use of opioids. The goal is to manage pain effectively while monitoring for signs of misuse or addiction.
Choice B reason:
Opioid analgesics are often ordered and are usually needed for managing severe pain in patients with sickle cell anemia. Pain episodes in sickle cell disease can be extremely severe and debilitating, requiring potent analgesics like morphine for relief. The management of acute vaso-occlusive pain in sickle cell disease often necessitates the use of opioids to provide adequate pain control.
Choice C reason:
Opioid analgesics, when medically indicated and used under proper medical supervision, rarely cause addiction. The risk of addiction is significantly lower when opioids are used appropriately for pain management in a controlled medical setting. The Mayo Clinic highlights that while opioids have addictive properties, their medical use for pain relief, especially in acute settings, is generally safe when monitored by healthcare professionals.
Choice D reason:
Opioid analgesics are not used only if other measures, such as ice packs, are ineffective. While non-pharmacological measures can be part of pain management, opioids are often necessary for managing severe pain episodes in sickle cell disease. The use of opioids is based on the severity of the pain and the clinical judgment of the healthcare provider.
Correct Answer is A
Explanation
Choice A reason:
Wearing cotton underpants is recommended to prevent urinary tract infections (UTIs) in young girls. Cotton is a breathable fabric that allows air to circulate, reducing moisture and creating an environment less conducive to bacterial growth. This helps to keep the genital area dry and clean, which is important in preventing UTIs.
Choice B reason:
Limiting trips to the bathroom is not recommended for preventing UTIs. In fact, it is important for young girls to urinate frequently to flush out bacteria from the urinary tract. Holding urine for extended periods can increase the risk of bacterial growth and infection. Therefore, encouraging regular bathroom trips is a better practice for preventing UTIs.
Choice C reason:
Decreasing salt intake is not directly related to preventing UTIs. While a healthy diet is important for overall health, there is no specific evidence linking salt intake to the prevention of urinary tract infections. The focus should be on practices that directly reduce the risk of bacterial growth and infection in the urinary tract.
Choice D reason:
Soaking in a bathtub, especially with bubble baths or perfumed soaps, can increase the risk of UTIs. These substances can irritate the urethra and create an environment conducive to bacterial growth. It is better to avoid prolonged baths with such products and instead opt for quick showers to maintain hygiene without increasing the risk of infection.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.