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 having them share a room with a child with active mumps may expose them to infection and worsen their condition. A child who is immunosuppressed due to leukemia or chemotherapeutic agents has a weakened immune system and is more susceptible to infections from bacteria, viruses, fungi, or parasites. Therefore, they should be placed in a private room or cohorted with another immunosuppressed child.
Choice B reason: This choice is incorrect because restricting oral fluids may cause dehydration and electrolyte imbalance in the child who is immunosuppressed due to leukemia or chemotherapeutic agents. A child who is immunosuppressed due to leukemia or chemotherapeutic agents may have increased fluid losses from vomiting, diarrhea, fever, or sweating. Therefore, they should be encouraged to drink adequate fluids to maintain hydration and electrolyte balance.
Choice C reason: This choice is incorrect because strict isolation may cause psychological distress and social isolation in the child who is immunosuppressed due to leukemia or chemotherapeutic agents. A child who is immunosuppressed due to leukemia or chemotherapeutic agents may benefit from protective isolation, which involves using standard precautions and additional measures such as wearing gloves, gowns, masks, or eye protection when in contact with the child or their body fluids. However, strict isolation, which involves limiting visitors and activities, may harm the child's emotional and developmental well-being.
Choice D reason: This choice is correct because using good handwashing is essential nursing care for a child who is immunosuppressed due to leukemia or chemotherapeutic agents. Handwashing is the most effective way to prevent the transmission of microorganisms that can cause infections. The nurse should wash their hands before and after touching the child or their belongings, and teach the child and their family members to do the same. The nurse should also use alcohol-based hand rubs when water and soap are not available.
Correct Answer is D
Explanation
Choice A: Urinary incontinence is a condition of involuntary loss of urine control, which can be caused by various factors, such as nerve damage, bladder dysfunction, or medication side effects. It is not always caused by neuroblastoma, which is a type of cancer that arises from immature nerve cells.
Choice B: Blood-fed is not a term that describes a neuroblastoma. Neuroblastoma is a type of cancer that arises from immature nerve cells, which can form tumors in various parts of the body, such as the adrenal glands, abdomen, chest, or spine.
Choice C: Tiny is not a term that describes a neuroblastoma. Neuroblastoma can vary in size and shape depending on the location and stage of the tumor. Some neuroblastomas can be very large and cause compression of nearby organs or structures.
Choice D: Unfortunately, much of the time, by the time a diagnosis has been made, metastasis has already occurred. This statement describes a neuroblastoma accurately. Neuroblastoma is a type of cancer that arises from immature nerve cells, which can spread rapidly to other parts of the body, such as the bones, liver, lymph nodes, or skin.
Metastasis is the process of cancer cells breaking away from the original tumor and forming new tumors elsewhere. Neuroblastoma often has no specific symptoms until it has metastasized, making it difficult to diagnose early and treat effectively.
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