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 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.
Correct Answer is B
Explanation
A. Incorrect. Measuring the group's work against the assigned objectives is a task role that belongs to the evaluator, who assesses the quality and effectiveness of the group's performance.
B. Correct. Noting the progress of the group toward assigned goals is a task role that belongs to the orienteer, who keeps track of where the group is heading and summarizes what has been accomplished.
C. Incorrect. Sharing experiences as an authority figure is a task role that belongs to the information giver, who provides factual data or personal knowledge to the group.
D. Incorrect. Offering new and fresh ideas on an issue is a task role that belongs to the initiator, who proposes new solutions or approaches to problems.
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