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 statement that best describes Tanner staging is option B. Tanner staging is a system used
to classify and assess the progression of puberty based on the development of both primary
and secondary sexual characteristics. It provides a framework for evaluating the physical
changes that occur during puberty, such as breast development in females, testicular
enlargement in males, pubic hair growth, and other secondary sexual characteristics. The
Tanner staging system includes several stages that represent the sequential progression of
puberty in individuals.
staging of puberty based on the initiation of primary sexual characteristics in (option A) is not
correct because it, does not encompass the full scope of Tanner staging, as it does not
consider the progression of secondary sexual characteristics.
staging of puberty based on the initiation of menarche (the onset of menstruation) and
nocturnal emissions, in (option C) is not correct. While menarche and nocturnal emissions are
significant events that occur during puberty, they do not encompass the entire Tanner staging
system, which involves a broader range of physical changes.
predictable stages of puberty based on chronologic age, in (option D) is not correct. Tanner
staging is based on the progression of physical changes and sexual maturation, rather than
being solely determined by chronological age. Puberty can vary in onset and duration among
individuals, making chronological age an unreliable indicator of pubertal development.
Correct Answer is D
Explanation
When the skin surface is caked with desquamated skin and sebaceous secretions after the removal of a cast, the nurse should suggest washing the area with warm water and soap. This will help to gently cleanse the skin and remove the accumulated material without causing unnecessary trauma or irritation.
Option A, applying powder to absorb the material, may not effectively remove the caked material and could potentially lead to further clumping or discomfort.
Option B, vigorously scrubbing the leg, can be harsh on the skin and may cause skin irritation, redness, or even abrasions. It is important to be gentle and avoid excessive scrubbing, especially on the fragile and recently exposed skin.
Option C, carefully picking the material off the leg, can increase the risk of skin injury or introduce bacteria into the skin. Picking at the skin should be avoided to prevent further damage or infection.
Therefore, option D, washing the area with warm water and soap, is the most appropriate and gentle method to remove the caked material from the skin surface
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