A nurse is assessing an infant who has intussusception.
Which of the following findings should the nurse expect?
Sausage-shaped abdominal mass.
Increased urinary output.
Constipation.
Board-like abdomen.
The Correct Answer is A
Choice A rationale:
A sausage-shaped abdominal mass is a classic sign of intussusception, a condition where one segment of the intestine telescopes into another, causing obstruction. This is a medical emergency that requires prompt intervention.
Choice B rationale:
Increased urinary output is not a characteristic finding of intussusception. Instead, the child may present with signs of dehydration due to vomiting, diarrhea, and decreased oral intake caused by the obstruction.
Choice C rationale:
Constipation is a symptom that can be associated with various gastrointestinal disorders but is not specific to intussusception. In intussusception, the child typically experiences severe abdominal pain, vomiting, and the classic sausage-shaped abdominal mass.
Choice D rationale:
A board-like abdomen can occur in conditions such as peritonitis, but it is not a typical finding in intussusception. The presence of a sausage-shaped abdominal mass is the hallmark sign of intussusception.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Maintaining balance when standing with eyes closed is a test of the vestibular system and cerebellar function, not the trigeminal nerve.
Choice B rationale:
Exhibiting a gag reflex when stimulated with a tongue blade is a test of the glossopharyngeal and vagus nerves, not the trigeminal nerve.
Choice C rationale:
The trigeminal nerve is responsible for sensory input from the face and motor functions such as biting and chewing. Symmetrical jaw strength when biting down indicates proper functioning of the trigeminal nerve, making choice C the correct answer.
Choice D rationale:
Correctly identifying specific scents is related to olfactory nerve function, not the trigeminal nerve.
Correct Answer is A
Explanation
Choice A rationale:
Increased respiratory rate is an expected finding in a severely dehydrated infant. Dehydration can lead to an increased breathing rate as the body tries to compensate for reduced blood volume and oxygenation. Respiratory rate may be rapid, and the infant may appear tachypneic. This compensatory mechanism helps maintain oxygen levels in the body.
Choice B rationale:
Capillary refill of 2 seconds is within the normal range and is not indicative of severe dehydration. Prolonged capillary refill time (>2 seconds) can be a sign of poor perfusion and dehydration, but a capillary refill time of 2 seconds is normal.
Choice C rationale:
Increased urine output is not an expected finding in severe dehydration. Dehydration leads to reduced urine output as the body tries to conserve fluids. In a dehydrated infant, urine output may be significantly decreased, indicating a lack of fluid intake and reduced renal perfusion.
Choice D rationale:
Hypertension is not a typical finding in severe dehydration. Dehydration often leads to decreased blood volume, which can result in low blood pressure rather than hypertension. Hypotension, not hypertension, is a common clinical manifestation of severe dehydration.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.