A nurse is caring for a male infant who has a palpable mass in the upper right quadrant and stools mixed with blood and mucus. The nurse should recognize that which of the following diagnoses is associated with these findings?
Hypertrophic pyloric stenosis
Intussusception
Inguinal hernia
Tracheoesophageal fistula
The Correct Answer is B
Choice A reason: Hypertrophic pyloric stenosis is a condition in which the pyloric sphincter becomes thickened and obstructs the passage of food from the stomach to the duodenum. It causes projectile vomiting, dehydration, and weight loss, but not a palpable mass or bloody stools.
Choice B reason: Intussusception is a condition in which a segment of the intestine telescopes into another segment, causing obstruction, inflammation, and ischemia. It causes a palpable mass in the upper right quadrant, abdominal pain, and stools mixed with blood and mucus, also known as "currant jelly" stools.
Choice C reason: Inguinal hernia is a condition in which a part of the intestine protrudes through a weak spot in the abdominal wall near the inguinal canal. It causes a bulge in the groin area, especially when the infant cries or strains. It does not cause a mass in the upper right quadrant or bloody stools.
Choice D reason: Tracheoesophageal fistula is a congenital anomaly in which there is an abnormal connection between the trachea and the esophagus. It causes excessive drooling, choking, coughing, and cyanosis during feeding, but not a palpable mass or bloody stools.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Red currant jelly stools are typically associated with intussusception, not pyloric stenosis. In pyloric stenosis, the stool would not have this appearance.
Choice B reason: Distended neck veins are not a clinical manifestation of pyloric stenosis. They are more commonly associated with cardiac or respiratory issues.
Choice C reason: Projectile vomiting is a classic symptom of pyloric stenosis. It occurs due to the obstruction at the pylorus, which prevents stomach contents from passing into the small intestine.
Choice D reason: A bulged abdomen is not specific to pyloric stenosis. While the abdomen may appear full, 'bulged' is not the precise term used to describe the manifestation in pyloric stenosis.
Correct Answer is A
Explanation
Choice A reason: This statement indicates a need for clarification, as sodium biphosphate/sodium phosphate is a laxative that can cause bowel perforation in a child with appendicitis. The nurse should question this prescription and avoid giving it to the child.
Choice B reason: This statement is correct, as maintaining NPO status is a standard intervention for a child with suspected appendicitis. It prevents further irritation of the appendix and prepares the child for possible surgery.
Choice C reason: This statement is correct, as monitoring oral temperature every 4 hours is a way to assess for signs of infection and inflammation in a child with suspected appendicitis. The nurse should also monitor for other symptoms such as abdominal pain, nausea, vomiting, and rebound tenderness.
Choice D reason: This statement is correct, as medicating the client for pain every 4 hours as needed is a way to provide comfort and relief for a child with suspected appendicitis. The nurse should use a pain scale to evaluate the effectiveness of the medication and report any changes in the pain level or location.
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