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
A. Autonomy is the ethical principle that respects the right of clients to make their own decisions and choices regarding their health care. Informed consent is a process that ensures that clients are fully informed of the benefits, risks, alternatives, and consequences of a proposed treatment or procedure, and that they voluntarily agree to it.
B. Nonmaleficence is the ethical principle that obliges health care providers to do no harm to clients, either intentionally or unintentionally. Informed consent does not directly promote this principle, although it may help to prevent harm by disclosing potential risks and complications.
C. Justice is the ethical principle that requires fair and equal treatment of all clients, regardless of their personal characteristics, preferences, or values. Informed consent does not directly promote this principle, although it may help to ensure that clients are not coerced or manipulated into accepting a treatment or procedure that they do not want or need.
D. Fidelity is the ethical principle that requires health care providers to be faithful and loyal to their clients, and to honor their commitments and promises. Informed consent does not directly promote this principle, although it may help to establish trust and rapport between clients and providers.
Correct Answer is ["B","C","E","F"]
Explanation
A. Blood pressure: A normal blood pressure for an adolescent is 110/70 mm Hg. The question does not provide the adolescent's blood pressure, so it cannot be determined if it requires follow-up or not.
B. Capillary refill: A normal capillary refill time is less than 2 seconds. A prolonged capillary refill time indicates impaired blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
C. Pedal pulse: A normal pedal pulse is +2 or +3. A weak pedal pulse (+1) indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
D. Heart rate: A normal heart rate for an adolescent is 60 to 100 beats per minute. The question does not provide the adolescent's heart rate, so it cannot be determined if it requires follow-up or not.
E. Skin temperature: A normal skin temperature is warm and dry. A cool skin temperature indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
F. Pain: A pain level of 10 on a scale of 0 to 10 indicates severe pain that needs to be managed with appropriate analgesics and nonpharmacological interventions.
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