A nurse is assisting with the care of a child who has suspected intussusception. Which of the following manifestations is an expected finding?

Projectile vomiting

Periorbital edema

Stools that contain currant jelly-like mucus

Visible gastric peristaltic waves

Answer and Explanation

The Correct Answer is C

Rationale:

A. Projectile vomiting: Projectile vomiting is more commonly associated with pyloric stenosis in infants, not intussusception. While vomiting may occur in intussusception, it is typically bilious and not forceful or projectile in nature.

B. Periorbital edema: Periorbital edema is typically related to renal or allergic conditions such as nephrotic syndrome or severe allergic reactions. It is not associated with gastrointestinal issues like intussusception.

C. Stools that contain currant jelly-like mucus: Intussusception causes bowel telescoping, leading to obstruction and compromised blood flow. This results in stools containing blood and mucus, often described as “currant jelly,” which is a hallmark symptom of the condition.

D. Visible gastric peristaltic waves: Visible peristalsis is more indicative of pyloric stenosis, where there is hypertrophy of the pyloric muscle. It is not typically seen in cases of intussusception.

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Correct Answer is D

Explanation

Rationale:

A. "You can apply counterpressure to your back with each position change.": Counterpressure is commonly used during labor to relieve back pain caused by fetal positioning. It is not relevant for postoperative cesarean pain, which is abdominal.

B. "You should change positions as little as possible.": Limiting movement after surgery can increase the risk of complications such as pneumonia and venous thromboembolism. Frequent, supported movement is encouraged to promote recovery and circulation.

C. "You should use patterned-paced breathing when changing positions.": Patterned-paced breathing is typically used during labor for pain management. While breathing techniques may offer mild comfort, they do not provide adequate support for incisional pain during movement.

D. "You can splint the incision with a pillow when changing positions.": Splinting the incision with a pillow provides support to the abdominal muscles, helping reduce tension and pain during movement. This is a safe and effective nonpharmacological strategy for post-cesarean clients.

A. Tilt the client's head forward during meals. B. Encourage socialization during meal times. C. Elevate the head of the client's bed to 30", D. Provide three large meals per day.

Correct Answer is A

Explanation

Rationale:

A. Tilt the client's head forward during meals: Tilting the head forward, also known as the chin-tuck technique, helps close the airway and reduce the risk of aspiration in clients with dysphagia. This position facilitates safer swallowing by improving bolus control and airway protection.

B. Encourage socialization during meal times: While social interaction is generally beneficial, clients with dysphagia require focused attention during meals to prevent choking or aspiration. Distractions can compromise concentration on swallowing techniques and safety precautions.

C. Elevate the head of the client's bed to 30": Although elevating the head of the bed helps reduce aspiration risk, a 30" elevation is not optimal for swallowing. A 45–90 degree upright position is typically recommended during meals to support safer swallowing mechanics.

D. Provide three large meals per day: Clients with dysphagia benefit more from small, frequent meals to reduce fatigue and lower the risk of aspiration. Large meals can overwhelm their ability to chew and swallow safely, increasing the risk of complications.

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A nurse is assisting with the care of a child who has suspected intussusception. Which of the following manifestations is an expected finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is contributing to the plan of care for a client who has dysphagia. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

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