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.

Pain rating

Vomiting

Temperature

Stool

Abdominal findings

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B,C"},"C":{"answers":"B"},"D":{"answers":"A,C"},"E":{"answers":"C"}}

• Pain rating: The child’s history describes sudden, severe abdominal pain causing the child to draw their knees to their chest, with periods of relief between episodes. This episodic, colicky pain is classic for intussusception, as the bowel telescopes and intermittently obstructs intestinal flow.

• Vomiting: The child vomited approximately 50 mL of light-colored emesis, consistent with the obstruction caused by intussusception. Vomiting can also occur in appendicitis due to peritoneal irritation, particularly if inflammation is in the right upper quadrant.

• Temperature: The child has a mild fever of 37.4° C (99.3° F). This low-grade fever can indicate inflammation of the appendix, making appendicitis a consideration. Intussusception usually does not present with fever unless there is ischemia or infection, which is not indicated.

• Stool: The parent reports blood and mucus in the stool, which is classic “currant jelly” stool seen in intussusception. Crohn’s disease may also present with blood and mucus due to chronic bowel inflammation, but the sudden onset and combination with severe colicky pain point more strongly toward intussusception.

• Abdominal findings: On assessment, the child’s abdomen is distended with hypoactive bowel sounds and tenderness in the right upper quadrant, and a small, oblong palpable mass is noted in the same area. These findings are highly specific for intussusception, representing the telescoped segment of bowel that can be palpated as a sausage-shaped mass.

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Correct Answer is D

Explanation

A. Ondansetron: Ondansetron is an antiemetic that works by blocking serotonin receptors in the chemoreceptor trigger zone. It does not significantly affect glucose metabolism and is not associated with hyperglycemia.

B. Guaifenesin: Guaifenesin is an expectorant that thins respiratory secretions to aid clearance. It has no known effect on blood glucose levels or carbohydrate metabolism.

C. Amoxicillin: Amoxicillin is a broad-spectrum penicillin antibiotic. While it treats bacterial infections, it does not typically alter glucose metabolism or cause hyperglycemia as an adverse effect.

D. Methylprednisolone: Methylprednisolone is a corticosteroid that increases gluconeogenesis, decreases peripheral glucose uptake, and antagonizes insulin action. These mechanisms can lead to hyperglycemia, making it the likely cause of the observed increase in the child’s blood glucose.

A. Evaluate the client's ability to help with repositioning B. Reposition the client without the use of assistive devices. C. Discuss the client's preferences for determining a repositioning schedule. D. Raise the side rails on both sides of the client's bed during repositioning.

Correct Answer is A

Explanation

A. Evaluate the client's ability to help with repositioning: Assessing the client’s strength, motor function, and level of cooperation is essential to determine how much assistance is needed and which repositioning techniques are safest. Stroke clients may have hemiplegia or weakness, and understanding their abilities prevents injury to both the client and the nurse.

B. Reposition the client without the use of assistive devices: Using assistive devices such as slide sheets, gait belts, or mechanical lifts is recommended for clients with limited mobility to reduce the risk of musculoskeletal injury. Repositioning without them increases the likelihood of strain or falls.

C. Discuss the client's preferences for determining a repositioning schedule: While client preferences can enhance comfort and adherence, safety and prevention of complications such as pressure injuries take priority. Scheduling should follow clinical guidelines rather than preference alone.

D. Raise the side rails on both sides of the client's bed during repositioning: Raising both side rails can create a fall hazard or limit safe access for the nurse during repositioning. Typically, one side rail may be raised as needed, while the other is lowered to allow safe maneuvering.

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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.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in the child's blood glucose. The nurse should identify this finding as an adverse effect of which of the following medications?

Correct Answer is D

Explanation

A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include?

A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following statements by the newly licensed nurse indicates an understanding of the procedure?

A nurse is initiating bladder retraining for a client who has urge urinary incontinence. Which of the following instructions should the nurse give the client?

A nurse is caring for a client at the clinic. Complete the following sentence by using the lists of options. The client is at risk for _____ as evidenced by _____ .

A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record?

A nurse in an emergency department is caring for a client who is actively bleeding from a stab wound to the thigh. Which of the following actions should the nurse take?

A nurse in a provider's office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department?

A newly licensed nurse is unsure if an assigned task is within their scope of practice. Which of the following resources should the nurse consult?

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.