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
Explanation
Choice A rationale
Lethargy, or excessive drowsiness and lack of energy, can be a sign of dehydration, electrolyte imbalance, or even bowel perforation in a child with intussusception. These are serious complications that require immediate medical attention. Normal temperature range is 36.5°C to 37.5°C (97.7°F to 99.5°F).
Correct Answer is ["B","C","E","G"]
Explanation
Choice A rationale
Nephrotic syndrome typically has a gradual onset of symptoms, developing over days to weeks, as protein loss in the urine accumulates. An abrupt onset is less characteristic.
Choice B rationale
Proteinuria, the presence of abnormally high levels of protein in the urine (normal range is less than 150 mg/24 hours), is a defining characteristic of nephrotic syndrome. Damage to the glomeruli in the kidneys leads to increased permeability and leakage of protein into the urine.
Choice C rationale
Hypoalbuminemia in the blood (normal range is 3.5 to 5.5 g/dL) is a key feature of nephrotic syndrome. The excessive loss of protein in the urine leads to a decrease in serum albumin levels.
Choice D rationale
Fever is not typically a primary symptom of nephrotic syndrome. While children with nephrotic syndrome can develop infections, fever is not a direct consequence of the underlying kidney dysfunction.
Choice E rationale
Hyperlipidemia, an elevated level of lipids (fats) in the blood (normal total cholesterol is less than 200 mg/dL), is commonly associated with nephrotic syndrome. The liver increases lipoprotein synthesis in response to the decreased serum albumin levels.
Choice F rationale
While a positive Group A beta-hemolytic streptococcal infection can lead to post-streptococcal glomerulonephritis, which can sometimes present with nephrotic features, it is not a common finding directly associated with the primary diagnosis of nephrotic syndrome itself.
Choice G rationale
Anasarca, which is severe generalized edema characterized by widespread swelling due to fluid retention, is a common finding in nephrotic syndrome. The low serum albumin levels reduce oncotic pressure in the blood vessels, leading to fluid shifting into the interstitial spaces. .
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