A nurse is caring for a 6-week-old infant who has pyloric stenosis. Which of the following clinical manifestations should the nurse expect?
Distended neck veins
Rigid abdomen
Projectile vomiting
Red currant jelly stools
The Correct Answer is C
Choice A: Distended neck veins are not a clinical manifestation of pyloric stenosis, which is a condition that causes the narrowing of the pylorus, which is the opening between the stomach and the small intestine. Distended neck veins are a sign of increased venous pressure, which can occur in conditions that affect the right side of the heart or cause fluid overload.
Choice B: Rigid abdomen is not a clinical manifestation of pyloric stenosis, but rather a sign of peritonitis, which is inflammation of the peritoneum, which is the membrane that lines the abdominal cavity. Peritonitis can be caused by infection, perforation, or trauma to any abdominal organ. A rigid abdomen indicates severe pain and inflammation in the abdominal cavity.
Choice C: Projectile vomiting is a clinical manifestation of pyloric stenosis, as it indicates forceful expulsion of stomach contents due to obstruction at the pylorus. Projectile vomiting can occur shortly after feeding and may contain undigested milk or formula. Projectile vomiting can cause dehydration, electrolyte imbalance, or weight loss.
Choice D: Red currant jelly stools are not a clinical manifestation of pyloric stenosis, but rather a sign of intussusception, which is a condition that causes telescoping of one segment of bowel into another. Intussusception can cause obstruction and ischemia of the bowel and lead to bleeding and necrosis. Red currant jelly stools indicate blood and mucus in the stool.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This choice is incorrect because mumps is not the common name for pertussis. Mumps is a viral infection that causes inflammation of the salivary glands, especially the parotid glands. It may cause symptoms such as fever, headache, and swelling of the cheeks or jaw. It can be prevented by vaccination with the measles-mumps-rubella (MMR) vaccine.
Choice B reason: This choice is correct because whooping cough is the common name for pertussis. Pertussis is a bacterial infection that causes severe coughing spells, which may be followed by a high-pitched whoop sound or vomiting. It may cause complications such as pneumonia, seizures, or brain damage, especially in infants and young children. It can be prevented by vaccination with the diphtheria-tetanus-pertussis (DTaP) vaccine.
Choice C reason: This choice is incorrect because the fifth disease is not the common name for pertussis. The fifth disease is a viral infection that causes a rash on the face, trunk, and limbs, which may resemble a slapped cheek appearance. It may cause mild symptoms such as fever, runny nose, or joint pain. It usually affects children and is self-limiting.
Choice D reason: This choice is incorrect because chickenpox is not the common name for pertussis. Chickenpox is a viral infection that causes an itchy rash with fluid-filled blisters all over the body. It may cause symptoms such as fever, headache, or loss of appetite. It can be prevented by vaccination with the varicella-zoster (VZV) vaccine.
Correct Answer is D
Explanation
Choice A: A video game is not a therapeutic play activity for a 4-year-old child who is distressed after an insulin injection, as it does not address the child's feelings or concerns about the injection. A video game may provide distraction or entertainment, but it does not help the child cope with or understand their condition.
Choice B: A period of play in the playroom is not a therapeutic play activity for a 4-year-old child who is distressed after an insulin injection, as it does not address the child's feelings or concerns about the injection. A period of play in the playroom may provide socialization or stimulation, but it does not help the child cope with or understand their condition.
Choice C: A storybook about a 4-year-old child is not a therapeutic play activity for a 4-year-old child who is distressed after an insulin injection unless the storybook is specifically about diabetes mellitus and insulin injections. A storybook about a 4-year-old child may provide identification or imagination, but it does not help the child cope with or understand their condition.
Choice D: A needleless syringe and a doll is a therapeutic play activity for a 4-year-old child who is distressed after an insulin injection, as it allows the child to express their feelings and concerns about the injection through role-playing and simulation. A needleless syringe and a doll can help the child cope with and understand their condition by providing mastery, control, and education.
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