A nurse is caring for a 6-week-old infant who has hypertrophic pyloric stenosis (HPS). Which of the following clinical manifestations should the nurse expect?
Ridged abdomen
Distended neck veins
Red currant jelly stools
Projectile vomiting
The Correct Answer is D
A. Rigid abdomen: A rigid abdomen is not a common finding in HPS. However, it is more typical in conditions such as intestinal obstruction.
B. Distended neck veins: Distended neck veins are not a typical manifestation of HPS. They may be associated with other cardiovascular or respiratory issues.
C. Red currant jelly stools: Red currant jelly-like stools are not typically seen in HPS. This description is often used to describe the appearance of stools in intussusception, which is a different gastrointestinal condition.
D. Projectile vomiting.
Hypertrophic pyloric stenosis is a condition in infants where the muscle at the outlet of the stomach (pylorus) becomes thickened and obstructs the passage of food from the stomach into the small intestine. Projectile vomiting is a characteristic symptom of HPS. The vomit is forceful and seems to shoot out of the infant's mouth, typically occurring after feeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Engaging the child in games with other children is important for social development, but it depends on the child's individual readiness and comfort level with social interactions. It's crucial to consider the child's temperament and developmental stage.
B. Encourage the child to feed himself finger foods.
At 18 months of age, children are typically developing their fine motor skills and independence. Encouraging self-feeding with finger foods is a developmentally appropriate activity. It promotes independence, fine motor skill development, and a positive feeding experience.
C. Allowing the child to walk independently on the nursing unit is appropriate if the child is developmentally ready and safe to do so. It promotes gross motor skill development and independence.
D. Holding and cuddling the child often is important for emotional and social development. However, the frequency and style of interaction should be individualized based on the child's preferences and needs. Some children may prefer more independence at this age.
Correct Answer is ["B","C","D"]
Explanation
A. Metabolic alkalosis is not a common acid-base imbalance associated with ARF. Instead, metabolic acidosis is more commonly observed due to the retention of metabolic waste products.
B. Water and sodium (Na) retention: In ARF, the kidneys are unable to effectively filter and excrete waste products and excess fluids. This leads to the retention of water and sodium, contributing to fluid overload.
C. Anemia: ARF can lead to decreased erythropoietin production by the kidneys, which can result in anemia due to reduced red blood cell production.
D. Hyperkalemia: The impaired kidney function in ARF may result in the inability to regulate potassium levels. Elevated levels of potassium (hyperkalemia) can be a dangerous complication.
E. Increased urinary output is not a typical finding in ARF. Instead, the hallmark of ARF is a reduction in urine output or oliguria.
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