A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD?
(You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
A
B
C
The Correct Answer is C
A. Incorrect. HD does not affect the eyes.
B. Incorrect. HD does not affect the respiratory system or cause chest manifestations.
C. Correct. Hirschsprung disease (HD) is a congenital disorder that affects the nerve cells in the colon, causing a lack of peristalsis and bowel obstruction. Infants with HD may have a distended abdomen due to fecal accumulation and gas.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
When a primigravida client confides in the practical nurse (PN) about being in an abusive relationship, the primary concern is the safety and well-being of the client and her unborn child.
Providing contact information for a women's shelter is the most appropriate response in this situation. Women's shelters provide a safe haven for individuals experiencing domestic violence and can offer immediate assistance, including shelter, counseling, legal support, and other resources.
In situations involving domestic violence, it is essential to prioritize the safety and well-being of the individual experiencing abuse. Connecting them with resources like women's shelters can provide the necessary support and assistance they need to escape the abusive relationship and protect themselves and their unborn child.
Correct Answer is D
Explanation
A. This choice is incorrect because an older adult client who reports constipation of 4 days is not an urgent situation that requires immediate attention. The nurse should assess the client's hydration status, bowel habits, and medication use, and provide education on dietary and lifestyle modifications to prevent constipation.
B. This choice is incorrect because a preschooler who has a skin rash is not an urgent situation that requires immediate attention. The nurse should assess the type, location, and distribution of the rash, as well as any history of allergies, exposure, or infection, and provide appropriate treatment and education.
C. This choice is incorrect because an adolescent who has a closed fracture is not an urgent situation that requires immediate attention. The nurse should assess the site of injury, neurovascular status, pain level, and immobilization device, and provide analgesia and education on fracture care.
D. This choice is correct because a middle adult client who has unstable vital signs is an urgent situation that requires immediate attention. The nurse should assess the client's level of consciousness, airway, breathing, circulation, and possible causes of instability, and initiate life-saving interventions.
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