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 B
Explanation
The correct answer is choice B. A feeling of fullness in the ear.
Choice A rationale:
Nausea and vomiting are not typical symptoms of chronic otitis media with effusion (OME). OME involves fluid accumulation in the middle ear without signs of acute infection. It is commonly seen in children and may cause mild hearing impairment and a feeling of fullness in the ear.
Choice B rationale:
A feeling of fullness in the ear is a common symptom of OME. The fluid accumulation in the middle ear can lead to a sensation of pressure or fullness, as well as mild hearing loss. This can impact a child's ability to hear and communicate effectively.
Choice C rationale:
Severe pain in the ear is more characteristic of acute otitis media (AOM), which is an infection of the middle ear with signs of inflammation. In OME, pain is typically not a prominent symptom unless there is an underlying AOM episode.
Choice D rationale:
Fever as high as 40°C (104°F) is not a typical symptom of OME. OME is generally a chronic condition without acute signs of infection such as fever. However, if a fever is present, it might indicate a concurrent infection that needs further evaluation.
Correct Answer is A
Explanation
The correct answer is choice A.
Choice A rationale:
Drawing is the most appropriate activity for developing fine motor skills in school-age children. Drawing involves precise hand movements, control of a writing instrument, and attention to detail. These skills contribute to fine motor skill development and hand-eye coordination.
Choice B rationale:
Singing is not directly related to fine motor skill development. While it can promote cognitive and social development, it does not require the same level of fine motor control as activities like drawing or writing.
Choice C rationale:
Swimming is a gross motor activity that focuses more on large muscle groups and overall coordination. It does not specifically target the refinement of fine motor skills.
Choice D rationale:
Soccer is also a gross motor activity that involves running, kicking, and coordination with teammates. While it promotes physical fitness and coordination, it does not emphasize the fine motor control required for activities like drawing.
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