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 C
Explanation
Choice A rationale
Limiting fluid intake is generally not indicated for atopic dermatitis unless there is a specific comorbid condition warranting fluid restriction. Maintaining adequate hydration is usually encouraged for overall skin health.
Choice B rationale
Promoting peeling of dead skin is not a primary goal in managing atopic dermatitis. The focus is on reducing inflammation, relieving itching, and maintaining skin hydration and barrier function, not necessarily on exfoliation.
Choice C rationale
Maintaining skin integrity and preventing infection are the most important goals in the care of a child with atopic dermatitis. The chronic inflammation and itching can lead to skin breakdown, increasing the risk of secondary bacterial or viral infections. Nursing interventions focus on gentle skin care, emollients, and managing itching.
Choice D rationale
Alcohol-based lotions should be avoided in children with atopic dermatitis as alcohol can dry and irritate the skin, exacerbating the condition and impairing skin integrity. Emollients that are fragrance-free and hypoallergenic are preferred to maintain skin hydration.
Correct Answer is A
Explanation
Choice A rationale
A tick is the arachnid responsible for transmitting Lyme disease. The characteristic rash associated with Lyme disease is erythema migrans, often described as a "bull's-eye" rash, which can appear days to weeks after a bite from an infected blacklegged tick (Ixodes scapularis or Ixodes pacificus). Spending time in wooded areas increases the risk of tick exposure.
Choice B rationale
Spiders are arachnids, but they are not the primary vector for Rocky Mountain spotted fever. Rocky Mountain spotted fever is caused by the bacterium Rickettsia rickettsii and is transmitted to humans through the bite of infected American dog ticks (Dermacentor variabilis) or Rocky Mountain wood ticks (Dermacentor andersoni). The rash associated with this disease typically starts on the wrists and ankles and spreads centrally.
Choice C rationale
Mites are arachnids, and certain types cause scabies, a contagious skin infestation characterized by intense itching and a pimple-like rash due to the burrowing of the Sarcoptes scabiei mite into the skin. While hiking in wooded areas could potentially lead to exposure to some types of mites, the rash of scabies has a distinct presentation and transmission pattern different from Lyme disease.
Choice D rationale
Chiggers are also mites (arachnids) that can be found in wooded areas. Their bites cause chigger dermatitis, characterized by intensely itchy red welts or bumps where the larvae have attached to the skin. While the history of hiking is relevant to potential exposure to chiggers, the rash and the associated disease are distinct from the erythema migrans rash of Lyme disease. .
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