The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented?
Ribbon-like stools
Profuse projectile vomiting
Bright red blood and mucus in the stools
Watery diarrhea
The Correct Answer is C
A. Ribbon-like stools
Explanation: Ribbon-like or pencil-thin stools are associated with conditions affecting the rectum, such as colorectal cancer, but they are not a typical sign of intussusception.
B. Profuse projectile vomiting
Explanation: Profuse projectile vomiting is not a typical sign of intussusception. Vomiting may occur, but it is not the primary characteristic feature.
C. Bright red blood and mucus in the stools
Explanation:
Intussusception is a condition in which one part of the intestine slides into another, causing a blockage. One of the classic signs of intussusception is the presence of "currant jelly" stools, which are characterized by a mixture of bright red blood and mucus in the stools. This occurs due to the compression of the blood vessels in the intestine, leading to bleeding and mucosal discharge.
D. Watery diarrhea
Explanation: Watery diarrhea is not a typical sign of intussusception. The condition is more commonly associated with abdominal pain, vomiting, and the characteristic "currant jelly" stools.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["260"]
Explanation
To calculate the total fluid intake, add the volumes of each item consumed:
Juice: ½ cup
1 cup = 240 mL
½ cup = 240 mL / 2 = 120 mL
Gelatin: 3 oz
1 oz ≈ 30 mL
3 oz = 3 * 30 mL = 90 mL
Ice pop: 1 oz
1 oz ≈ 30 mL
1 oz = 30 mL
Ginger ale: 20 mL
Now, add these values:
120 mL (juice) + 90 mL (gelatin) + 30 mL (ice pop) + 20 mL (ginger ale) = 260 mL
Therefore, the nurse should record 260 mL as the child's fluid intake.
Correct Answer is D
Explanation
A. Diarrhea
Explanation: Diarrhea is not a typical sign of Hirschsprung's disease. Instead, the condition is associated with constipation due to the obstructed passage of stool.
B. Regurgitation of feedings
Explanation: Regurgitation of feedings is not a characteristic sign of Hirschsprung's disease. It may be seen in other gastrointestinal conditions, but not specifically in this disorder.
C. Projectile vomiting
Explanation: Projectile vomiting is not a typical sign of Hirschsprung's disease. It may be associated with conditions such as pyloric stenosis, but it is not a characteristic feature of Hirschsprung's disease.
D. Foul-smelling ribbon-like stools
Explanation:
Hirschsprung's disease is a congenital condition characterized by the absence of ganglion cells in the rectum and a portion of the colon. The lack of ganglion cells results in functional obstruction, causing stool to accumulate in the affected area. One of the hallmark signs is the presence of foul-smelling, ribbon-like stools, often described as "fecal pellets" or "pellets" due to the obstructed passage of stool.
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