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 A
Explanation
An hour before meals and at bedtime.
Choice A rationale:
Scheduling chest physiotherapy an hour before meals and at bedtime is optimal. This timing helps prevent aspiration during meals and aids in clearing secretions before sleep. It complements the patient's meal schedule and sleep routine.
Choice B rationale:
Every six hours around the clock could disrupt the patient's sleep and meal times. Chest physiotherapy might not align well with the patient's daily activities, potentially affecting treatment compliance and effectiveness.
Choice C rationale:
Performing chest physiotherapy upon awakening and after meals might increase the risk of aspiration during meals. Clearing airways before meals is safer, and performing it right after meals could cause discomfort.
Choice D rationale:
Evenly spaced physiotherapy when awake lacks synchronization with meal and sleep times. This approach might not optimize treatment effects and patient convenience.
Correct Answer is D
Explanation
Choice A rationale:
The patient ties his shoelaces. This choice is incorrect as most 3-year-olds lack the fine motor skills required to tie shoelaces independently.
Choice B rationale:
The patient gives his first and last name. This choice is also incorrect, as most 3-year-olds might not have developed language skills to provide their full name accurately.
Choice C rationale:
The patient can tell time. This choice is unrealistic for a 3-year-old, as telling time involves cognitive and conceptual abilities that are not yet developed at this age.
Choice D rationale:
The patient draws a stick figure with six parts. This choice is correct. Around age 3, children usually start drawing simple figures with a head, arms, legs, and possibly facial features, totaling around six parts. This reflects appropriate developmental milestones for a child of this age.
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