A nurse in an acute care facility is caring for a toddler.
For each assessment finding below, click to specify if the assessment finding is consistent with Crohn's disease, appendicitis, or intussusception. Each finding may support more than 1 disease process.
Stool
Abdominal findings
Pain rating
Vomiting
Temperature
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"A,B,C"},"D":{"answers":"B,C"},"E":{"answers":"A,B"}}
Rationale:
• Stool: The presence of blood and mucus in the stool (“currant jelly” stool) is classic for intussusception, caused by ischemia and mucosal sloughing of the affected bowel segment.
• Abdominal findings: A distended abdomen with a small, palpable, oblong mass in the right upper quadrant is characteristic of the telescoping bowel seen in intussusception.
• Pain rating: Severe, intermittent, colicky abdominal pain causing the child to draw knees to chest is hallmark of intussusception due to periodic intestinal obstruction and ischemia. Children with Crohn’s may report chronic mild to moderate pain, often intermittent. Pain in appendicitis is usually steady, localized and worsens over time.
• Vomiting : Vomiting is common in intussusception due to partial bowel obstruction, often light-colored and non-bilious in early stages. In appendicitis, nausea and vomiting are common early symptoms.
•Temperature: In Crohn's disease low-grade fever is common due to the chronic inflammatory process, while in appendicitis, low-grade fever is common due to inflammation or early infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. "Placement of the catheter is confirmed by a CT scan.": Catheter placement is not routinely confirmed by CT scan. Instead, correct placement of a central venous catheter is verified by a chest X-ray immediately after insertion to ensure proper tip location.
B. "You will be under general anesthesia for this procedure.": General anesthesia is not required for placement of a nontunneled percutaneous central venous catheter. The procedure is typically performed using local anesthesia and aseptic technique at the bedside.
C. "The provider will wear a mask while performing the procedure.": The provider wears a mask, sterile gown, gloves, and cap as part of strict sterile technique during insertion to prevent catheter-related bloodstream infections.
D. "Your head will be elevated as high as possible while the catheter is inserted.": The client’s head is not elevated during insertion. Instead, a flat or slight Trendelenburg position is used to distend neck veins and reduce the risk of air embolism.
Correct Answer is C
Explanation
Rationale:
A. Call the pharmacist for clarification of the medication contraindications: While the pharmacist can provide medication information, it is the provider’s responsibility to evaluate the appropriateness of the prescription and modify it if needed.
B. Administer the medication as prescribed: Administering amoxicillin to a client allergic to penicillin places the client at risk for an allergic reaction, including anaphylaxis, since both drugs are in the same class.
C. Discuss the prescription with the health care provider: Amoxicillin is a penicillin derivative and contraindicated for clients with penicillin allergies. The nurse should immediately clarify the prescription with the provider before administration to ensure client safety.
D. Place an incident report in the medical record: Incident reports are used after an error or near-miss has occurred, not before a potential error is prevented. They are also never placed in the client’s medical record.
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