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 D
Explanation
Rationale:
A. "The provider can give you a referral for your baby to see an infectious disease provider.": Referring to a specialist does not address the parents’ knowledge or concerns about immunizations. The priority is to engage in a discussion to understand their perspective.
B. "Your baby's immunizations should be up to date before they are able to travel with you by airplane.": Framing immunizations only around travel requirements may seem judgmental and does not address the broader health benefits of vaccination.
C. "You don't have to immunize your baby against diseases that are no longer common.": This statement is misleading because many vaccine-preventable diseases can reemerge if immunization rates drop. It could reinforce misconceptions rather than promoting safe health practices.
D. "Let's talk about what you already know about immunizing your baby.": Beginning with an open-ended, nonjudgmental discussion allows the nurse to assess the parents’ knowledge, beliefs, and concerns. This approach supports informed decision-making and provides an opportunity for accurate, tailored education about vaccines.
Correct Answer is B
Explanation
Rationale:
A. "Can you tell me more about the surgery I am having?": Before signing consent, the client should already have received complete information about the nature, purpose, risks, and benefits of the surgery from the provider.
B. "Signing this form indicates that I give my permission for the surgery, right?": Informed consent is a legal and ethical document granting permission for the procedure. It shows that the client comprehends their role in authorizing the surgery after receiving adequate information from the healthcare provider.
C. "I will talk with the doctor about my surgery when I get into the operating room.": Consent discussions should occur before entering the operating room. The client must have all questions answered and sign consent prior to sedation or anesthesia to ensure voluntary decision-making.
D. "Every so often, I think about whether or not to have this surgery.": This response suggests indecision and lack of informed readiness for the procedure. The nurse must notify the provider so further discussion can occur to address concerns and ensure the client’s consent is fully informed and voluntary.
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