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A nurse in an acute care facility is caring for a toddler.

Exhibits

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.

Temperature

Vomiting

Pain rating

Abdominal findings

Stool

Answer and Explanation

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

Temperature: A temperature of 37.4°C is within normal limits and does not specifically support any of the three conditions. While low-grade fever may be seen in appendicitis or Crohn’s flares, the absence of fever at this time limits its diagnostic value in this case.
Vomiting: Vomiting in intussusception is common and often non-bilious in early stages, aligning with the child's light-colored emesis. Vomiting also occurs in appendicitis, especially in the early stages. However, it is not a prominent or early symptom of Crohn’s disease unless obstruction is present.
Pain rating: Severe, intermittent abdominal pain where the child draws their knees to the chest and then returns to normal behavior is a classic symptom of intussusception. Neither Crohn’s disease nor appendicitis typically presents with this pattern, appendicitis pain is usually constant and worsening, while Crohn’s pain is chronic and non-episodic.
Abdominal findings: A distended abdomen with hypoactive bowel sounds and a palpable sausage-shaped mass in the right upper quadrant is highly indicative of intussusception. These findings are not characteristic of appendicitis, which usually involves RLQ pain, or Crohn’s, which rarely presents with a discrete palpable mass.
Stool: The presence of blood and mucus in the stool ("currant jelly stool") is strongly associated with intussusception and may also occur in Crohn’s disease during flares due to colonic inflammation. Appendicitis does not typically cause bloody or mucoid stools, making this finding inconsistent with that diagnosis.

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Correct Answer is D

Explanation

Rationale:

A. Provide a tracheostomy tray at the bedside: A tracheostomy tray is not routinely required for seizure precautions, as airway obstruction in seizures is usually managed through positioning and suctioning.

B. Place the client in supine position: The supine position can increase the risk of airway obstruction and aspiration after a seizure. A side-lying position is preferred to help maintain an open airway and promote drainage of secretions.

C. Place a plastic tongue depressor at the client's bedside: Placing any object in a client’s mouth during or after a seizure can cause injury to the teeth, gums, or airway. Modern seizure precautions avoid using tongue blades or depressors entirely.

D. Insert an IV saline lock: Having IV access readily available allows rapid administration of emergency medications such as benzodiazepines if the client experiences another seizure. This intervention supports prompt treatment and stabilization.

A. The client is allergic to penicillin. B. The client's parent is in a skilled nursing facility. C. The client has two small children at home. D. The client lives in a two-story home.

Correct Answer is D

Explanation

A. The client is allergic to penicillin: Medication allergies are critical for the nurse and prescriber to know, but they are not directly relevant to occupational therapy planning.

B. The client's parent is in a skilled nursing facility: While this may influence social support, it is not directly relevant to the client’s rehabilitation needs or adaptive strategies for activities of daily living.

C. The client has two small children at home: Knowing family responsibilities can help plan overall care, but the specific home environment is more critical for occupational therapy interventions.

D. The client lives in a two-story home: The home environment, including stairs, affects mobility, accessibility, and safety after amputation. Reporting this information is essential for planning adaptive equipment, home modifications, and safe discharge.

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A nurse in an acute care facility is caring for a toddler. Exhibits 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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is implementing seizure precautions for a client who has had a tonic-clonic seizure. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is D

Explanation

A nurse is caring for a client who is recovering from an amputation of her right arm below the elbow. Which of the following information should the nurse report to the occupational therapist?

Correct Answer is D

Explanation

A charge nurse is delegating tasks for a group of clients on a medical surgical unit. Which of the following tasks should the nurse delegate to the assistive personnel?

A nurse is planning a community health program about Parkinson's disease. Which of the following interventions should the nurse include as a tertiary prevention strategy?

A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?

A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?

A nurse is reviewing the facility's safety protocols concerning newborn abduction with the parent of a newborn. Which of the following client statements indicates an understanding of the teaching?

A nurse is assessing a school-age child who has moderate dehydration due to diarrhea and vomiting. Which of the following manifestations should the nurse expect?

A charge nurse is delegating care for a group of clients. Which of the following tasks should the charge nurse assign to a licensed practical nurse?

A nurse is caring for a client who became physically aggressive and had to be placed in mechanical restraints. Which of the following actions should the nurse take while the client is in restraints?

A nurse in an acute care facility is caring for a toddler.

Exhibits

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.