Which of these assessments is the priority for an infant who is diagnosed with Hirschsprung disease?
Total white blood cell count 7,000/mm.
Serum potassium 4.2 mEq/L.
Nonbilious vomiting.
Watery diarrhea.
The Correct Answer is C
Choice A rationale:
While monitoring the total white blood cell count is important, it is not the priority assessment for a child with Hirschsprung disease. The disease primarily affects the gastrointestinal system.
Choice B rationale:
Serum potassium level within the normal range (4.2 mEq/L) is relevant, but it doesn't take precedence over assessing symptoms directly related to Hirschsprung disease.
Choice C rationale:
Nonbilious vomiting could indicate a bowel obstruction, a potential complication of Hirschsprung disease. Prompt assessment is necessary to prevent further complications.
Choice D rationale:
Watery diarrhea might occur in Hirschsprung disease, but it's not as urgent as addressing vomiting, which could indicate a more immediate problem like bowel obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Monitoring the cast daily for foul odors is a proper action to identify potential infection.
Choice B rationale:
Bringing the child for frequent checkups to the clinic is important to ensure the cast is healing properly.
Choice C rationale:
Using the cast stabilizing bar to turn the child can be concerning. There's no mention of a cast stabilizing bar, so this statement suggests a lack of understanding or misinformation.
Choice D rationale:
Massaging the skin around the edges of the child's cast can help prevent skin irritation, so it's an appropriate action.
Correct Answer is D
Explanation
Choice A rationale:
Elevating the patient's buttocks off the bed is appropriate in Bryant's traction, ensuring effective countertraction and alignment of the fractured bone. This position doesn't compromise traction function.
Choice B rationale:
Proper weight suspension, free of interference, prevents inadequate traction. This maintains the pulling force needed for fracture reduction and immobilization. No compromise is indicated here.
Choice C rationale:
Flexing the patient's hips at a 90-degree angle promotes proper body alignment. Although this angle might vary depending on the specific type of traction, it's not an immediate indication of traction compromise.
Choice D rationale:
Placing a knot in the rope against a pulley impedes the smooth functioning of the traction system. This could lead to a decrease in the applied traction force, potentially compromising fracture alignment and healing.
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