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 D
Explanation
Choice A reason: This choice is incorrect because the BCG vaccine is not recommended for adolescents in the United States. The BCG vaccine is a vaccine that protects against tuberculosis (TB), a bacterial infection that affects the lungs and other organs. It may be used for children who live in countries where TB is common or who have a high risk of exposure to TB, but it is not routinely given in the United States because of the low incidence of TB and the possibility of false-positive results on TB skin tests.
Choice B reason: This choice is incorrect because the pneumococcal polysaccharide vaccine is not recommended for adolescents unless they have certain medical conditions. The pneumococcal polysaccharide vaccine is a vaccine that protects against pneumococcal disease, a bacterial infection that can cause pneumonia, meningitis, or sepsis. It may be used for adults who are 65 years or older or who have chronic diseases, immunosuppression, or cochlear implants, but it is not routinely given to adolescents who are healthy.
Choice C reason: This choice is incorrect because the influenza vaccine is recommended for adolescents every year, not just before college. The influenza vaccine is a vaccine that protects against influenza, a viral infection that affects the respiratory system. It may be given as an injection or a nasal spray, and it may prevent or reduce the severity of influenza and its complications. It is recommended for everyone who is 6 months or older, especially those who have a high risk of influenza-related complications.
Choice D reason: This choice is correct because the meningococcal polysaccharide vaccine is recommended for adolescents before college. The meningococcal polysaccharide vaccine is a vaccine that protects against meningococcal disease, a bacterial infection that can cause meningitis, septicemia, or death. It may be given as a single dose or a booster dose, and it may prevent outbreaks of meningococcal disease in crowded settings such as dormitories or military barracks. It is recommended for adolescents who are 11 to 12 years old, with a booster dose at 16 years old, or for those who are entering college and have not been previously vaccinated.
Correct Answer is C
Explanation
Choice A: Shingles is a viral infection that causes a painful rash, usually on one side of the body. It is caused by the same virus that causes chickenpox. Shingles is not related to tinea pedis, which is a fungal infection.
Choice B: Valley fever is a fungal infection that affects the lungs and can cause flu-like symptoms, such as fever, cough, and chest pain. It is caused by inhaling spores from a fungus that grows in dry soil. Valley fever is not related to tinea pedis, which affects the skin of the feet.
Choice C: Athlete's foot is a common name for tinea pedis, which is a fungal infection that affects the skin between the toes and on the soles of the feet. It can cause itching, burning, scaling, and cracking of the skin. Athlete's foot is contagious and can be spread by direct contact or by sharing shoes, socks, or towels.
Choice D: Fever blister is another name for a cold sore, which is a small blister that forms on or near the lips. It is caused by a type of herpes virus that can be transmitted by kissing or sharing utensils. Fever blister is not related to tinea pedis, which is a fungal infection.
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