A child has been diagnosed with Hirschsprung's disease. Which of the following findings would the nurse expect the parents to report in the child's history? Select all that apply.
Ribbon-like stools.
Distended abdomen.
Chronic constipation.
Black and tarry stools.
Correct Answer : A,B,C
Choice A rationale:
Ribbon-like stools are a classic sign of Hirschsprung's disease, indicating narrowed or obstructed bowel segments due to the absence of ganglion cells in the intestine's muscular layers.
Choice B rationale:
A distended abdomen is common in Hirschsprung's disease due to the accumulation of stool and gas in the narrowed segments of the intestine.
Choice C rationale:
Chronic constipation is a result of the dysfunctional intestinal motility caused by Hirschsprung's disease. The absence of ganglion cells leads to a lack of peristalsis and difficulty passing stools.
Choice D rationale:
Black and tarry stools are indicative of upper gastrointestinal bleeding, often caused by conditions like peptic ulcers. This finding is not directly related to Hirschsprung's disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The identification band falling off the patient's leg is a documentation concern and doesn't require immediate action unless the patient is at risk of wandering or abduction.
Choice B rationale:
IV fluids should be changed every 24 hours to prevent bacterial growth and infection. Using fluids that are 48 hours old increases the risk of introducing infection to the patient.
Choice C rationale:
The crib rails being halfway up is not an immediate concern unless the child is at risk of falling or climbing out of the crib.
Choice D rationale:
Damp bed linen can be addressed during the next bedding change. It may not require immediate action unless the patient's skin integrity is at risk.
Correct Answer is B
Explanation
Choice A rationale:
A blood pressure of 110/68 mmHg is within the normal range for a 14-year-old and does not directly relate to the management of ulcerative colitis.
Choice B rationale:
Ulcerative colitis can lead to chronic inflammation and blood loss in the gastrointestinal tract, resulting in anemia. Monitoring the hemoglobin level is crucial to assess the severity of anemia and the need for interventions.
Choice C rationale:
While weight loss is a concern, hemoglobin level provides more direct information about the impact of ulcerative colitis on the client's health.
Choice D rationale:
Serum sodium level of 135 mEq/L is within the normal range and does not take precedence over addressing potential anemia and its impact on the client's well-being.
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