Which assessment finding should the nurse expect in an infant with Hirschsprung disease?
Constipation with passage of foul-smelling, ribbon-like stools
Diarrhea
Foul-smelling, fatty stools
"Currant jelly" stools
The Correct Answer is A
The assessment finding that the nurse should expect in an infant with Hirschsprung disease is option A, constipation with the passage of foul-smelling, ribbon-like stools. Hirschsprung disease is a congenital condition characterized by the absence of ganglion cells in the distal part of the colon, leading to functional obstruction. The affected segment of the colon lacks the normal peristaltic movements, resulting in an accumulation of faecal matter. The stools passed by infants with Hirschsprung disease are often constipated, and the narrow, ribbon- like appearance is a result of the narrowed segment of the colon.
diarrhea (option B) is incorrect because it, is not typically associated with Hirschsprung disease. Instead, the condition presents with constipation due to the obstructed bowel.
foul-smelling, fatty stools in (option C) is incorrect because it, is not characteristic of Hirschsprung disease. This finding may be associated with malabsorption disorders such as cystic fibrosis or celiac disease, but not specifically with Hirschsprung disease.
"currant jelly" stools in (option D) is incorrect because it, is a term commonly used to describe the stools seen in intussusception, which is a different condition involving the telescoping of one segment of the bowel into another. It is not an expected finding in Hirschsprung disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The regulation of acid-base balance in the body involves multiple systems working together. The respiratory system, renal system, and chemical-buffering systems play key roles in maintaining the balance of acids and bases in the body.
The respiratory system helps regulate acid-base balance through the control of carbon dioxide (CO2) levels in the blood. By adjusting the rate and depth of breathing, the respiratory system can increase or decrease the elimination of CO2, which affects the pH of the blood.
The renal system (kidneys) plays a crucial role in regulating acid-base balance by controlling the excretion and reabsorption of hydrogen ions (H+) and bicarbonate ions (HCO3-) in the urine. The kidneys can excrete excess acids or bases to help maintain the body's pH within a normal range.
The chemical-buffering systems involve various chemical compounds in the body that can absorb or release hydrogen ions to help maintain pH balance. Examples of chemical buffers include bicarbonate ions (HCO3-), phosphate ions (HPO4-), and proteins.
the cardiovascular and integumentary systemin (option A) is incorrect because they, are not primarily responsible for regulating acid-base balance in the body.
Correct Answer is A
Explanation
A change in status that should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury is confusion and altered mental status. As intracranial pressure increases, it can affect brain function and lead to neurological changes, including confusion, disorientation, irritability, decreased level of consciousness, or other alterations in mental status. These changes indicate that the brain is being compressed and compromised, and immediate intervention is required.
Option B, increased diastolic pressure with narrowing pulse pressure in (option B) is incorrect because it, can be a sign of increased ICP, but it is not specific to head injuries and can be influenced by other factors such as pain, anxiety, or systemic conditions. It is important to consider the overall hemodynamic status of the child and assess for additional signs and symptoms of increased ICP.
irregular, rapid heart rate in (option C), can be a sign of increased ICP, but it is not specific to head injuries and can be influenced by other factors such as pain, anxiety, or other medical conditions. Assessment of heart rate should be considered along with other signs and symptoms of increased ICP.
rapid, shallow breathing, in (option D) can be a sign of increased ICP, but it is not specific to head injuries and can be influenced by other factors such as pain, anxiety, or respiratory conditions. Respiratory assessment should be considered along with other signs and symptoms of increased ICP.
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