What is the most appropriate nursing action when a child with a probable intussusception has a normal, brown stool?
Take vital signs, including blood pressure.
Auscultate for bowel sounds.
Measure abdominal girth.
Notify the practitioner.
The Correct Answer is C
The correct answer is Choice C: Measure abdominal girth.
Choice A rationale:
Taking vital signs, including blood pressure, is important in assessing the overall health status of a child, but it might not provide specific information about a probable intussusception. Blood pressure is not typically affected in a way that directly relates to intussusception.
Choice B rationale:
Auscultating for bowel sounds is an important assessment technique in various gastrointestinal conditions, but it may not be the most appropriate immediate action when dealing with a probable intussusception. While bowel sounds might be diminished or absent in intussusception, the priority should be on assessing other signs and symptoms.
Choice C rationale:
Measuring abdominal girth is an essential nursing action when a child with a probable intussusception has a normal, brown stool. Intussusception is the telescoping of one segment of the intestine into another, often leading to bowel obstruction. Abdominal distension or girth measurement can provide valuable information about the progression of the condition and potential obstruction.
Choice D rationale:
Notifying the practitioner is an important step, but it might not be the most immediate action required. Assessing and monitoring the child's condition should be the initial response to gather more information before notifying the practitioner.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Treating the underlying disease.
Choice A rationale:
Administration of digoxin. Administering digoxin is not the initial goal for the treatment of secondary hypertension. Digoxin is a medication commonly used to treat heart failure and certain arrhythmias, but it is not a primary intervention for hypertension. The rationale for this choice being incorrect lies in the fact that digoxin primarily affects the heart's contractility and is not a preferred option for managing high blood pressure.
Choice B rationale:
Weight control and diet. Weight control and dietary modifications are important aspects of managing hypertension, both primary and secondary. However, they are not the initial goal for the treatment of secondary hypertension. While these lifestyle modifications can contribute to blood pressure reduction, the primary focus in secondary hypertension is to identify and address the underlying condition causing the high blood pressure.
Choice C rationale:
Treating the underlying disease. Correct Answer. The initial goal for the treatment of secondary hypertension is to address the underlying disease or condition that is causing the elevated blood pressure. Unlike primary hypertension, which often lacks a specific underlying cause, secondary hypertension results from an identifiable condition such as kidney disease, hormonal disorders, or certain medications. Treating the root cause can lead to blood pressure normalization.
Choice D rationale:
Administration of β-adrenergic receptor blockers. Administering β-adrenergic receptor blockers is not typically the initial goal for the treatment of secondary hypertension. While these medications can lower blood pressure by blocking the effects of adrenaline and reducing heart rate, they are not the first-line approach for addressing the underlying cause of secondary hypertension.
Correct Answer is D
Explanation
The correct answer is choice D. Give small amounts of favorite fluids frequently to prevent dehydration.
Choice A rationale:
Having the child wear heavy clothing to prevent chilling is not an appropriate nursing intervention for an infant with an elevated temperature. Infants are more susceptible to temperature regulation issues, and heavy clothing could exacerbate their discomfort and potentially raise their body temperature further.
Choice B rationale:
Giving tepid water baths to reduce fever is not recommended for fever management in infants. Tepid baths might cause discomfort and shivering, which could lead to increased heat production and potential elevation of body temperature.
Choice C rationale:
Encouraging food intake to maintain caloric needs is important, but it might not be well-tolerated by an infant with an elevated temperature and upper respiratory tract infection. Infants often have reduced appetite during illness.
Choice D rationale:
Giving small amounts of favorite fluids frequently to prevent dehydration is an appropriate nursing intervention. Fever and elevated temperature can lead to increased fluid loss through sweating and increased respiratory rate. Offering small, frequent fluid intake helps maintain hydration and prevent dehydration. Using favorite fluids can also encourage the child to drink more.
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