The nurse is evaluating a 7-month-old infant brought in for excessive crying and vomiting.
Which finding supports a diagnosis of intussusception?
Currant jelly stools and drawing knees to chest.
Ribbon-like stools and visible peristalsis.
Explosive watery diarrhea and fever.
Bright red blood in stool with no other symptoms.
The Correct Answer is A
Choice A rationale
Currant jelly stools (stools mixed with blood and mucus) and drawing the knees to the chest are classic signs and symptoms of intussusception in infants. The telescoping of one part of the intestine into another leads to bowel obstruction, inflammation, and bleeding, resulting in the characteristic stool appearance and abdominal pain that causes the infant to draw their knees up in an attempt to relieve the discomfort.
Choice B rationale
Ribbon-like stools and visible peristalsis are more characteristic of Hirschsprung's disease (congenital aganglionic megacolon), a condition where a segment of the colon lacks nerve cells, impairing motility and leading to constipation and a narrowed segment of the bowel. Visible peristalsis can occur due to the bowel trying to push stool through the narrowed segment.
Choice C rationale
Explosive watery diarrhea and fever are typical signs of gastroenteritis, an inflammation of the gastrointestinal tract usually caused by a viral or bacterial infection. While vomiting can occur in both conditions, the stool characteristics and the presence of fever are more indicative of gastroenteritis rather than intussusception.
Choice D rationale
Bright red blood in the stool without other symptoms is less specific to intussusception. While blood can be present, it is usually mixed with mucus, giving the currant jelly appearance. Bright red blood alone might suggest other conditions like anal fissures or lower gastrointestinal bleeding. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Ensuring suction equipment is readily available is crucial for a child with a history of seizures because they are at an increased risk of aspiration during or immediately following a seizure. Suctioning helps to clear the airway of saliva, vomitus, or other secretions, preventing respiratory complications.
Choice C rationale
Padding the side rails of the child's bed provides a protective barrier against injury during a seizure. Tonic-clonic seizures involve sudden, uncontrolled muscle contractions that can cause the child to hit the side rails, potentially leading to bruising or more serious injuries. Padding helps to cushion these impacts.
Choice D rationale
Educating parents on how to administer rectal diazepam for breakthrough seizures at home empowers them to manage prolonged or clustered seizures promptly. Rectal diazepam is a benzodiazepine medication that can effectively stop a seizure, reducing the risk of status epilepticus, a medical emergency.
Correct Answer is B
Explanation
Choice A rationale
Pain is a common symptom in superficial and partial-thickness burns where nerve endings are still intact. While pain indicates tissue damage, the absence of pain in a burn area can signify deeper and more severe injury where nerve endings have been destroyed.
Choice B rationale
No pain with pale, leathery skin is a characteristic finding of a full-thickness (third-degree) burn. The destruction of nerve endings eliminates pain sensation, and the skin appears dry, leathery, and may be white, charred, or translucent due to damage to all skin layers and underlying tissue.
Choice C rationale
Mild erythema, or redness of the skin, is characteristic of a superficial (first-degree) burn, such as a sunburn. These burns involve only the epidermis and are typically painful and without blisters.
Choice D rationale
Blister formation is a hallmark of partial-thickness (second-degree) burns, which involve the epidermis and part of the dermis. These burns are typically painful and moist.
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.