A nurse is caring for a male infant who has a palpable, sausage-shaped 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?
Intussusception
Tracheoesophageal fistula
Hypertrophic pyloric stenosis
Inguinal hernia
The Correct Answer is A
A. Intussusception typically presents with a palpable, sausage-shaped mass in the abdomen and stools mixed with blood and mucus.
B. Tracheoesophageal fistula presents with respiratory distress and may involve aspiration, but it does not typically present with abdominal mass or bloody stools.
C. Hypertrophic pyloric stenosis presents with projectile vomiting and may cause dehydration but does not typically present with bloody stools.
D. Inguinal hernia presents with a bulge in the groin area but is not typically associated with bloody stools or abdominal mass.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A flaccid abdomen might be present but is not specific for a ruptured appendix.
B. A low-grade fever may be present in both uncomplicated and perforated appendicitis.
C. A sudden decrease in abdominal pain after a period of worsening pain can indicate a ruptured appendix, which is life-threatening.
D. Absent Rovsing's sign (pain in the right lower quadrant when pressure is applied to the left lower quadrant) is not indicative of perforation but rather a sign of localized tenderness.
Correct Answer is A,B,C,D
Explanation
A. Inspection: The nurse begins with a visual examination of the abdomen, looking for any abnormalities in skin color, shape, or movement.
B. Auscultation: Next, the nurse listens to the bowel sounds using a stethoscope. This step is performed before palpation to avoid altering the bowel sounds.
C. Superficial palpation: The nurse gently presses the surface of the abdomen to assess for any tenderness, distension, or masses.
D. Deep palpation: Finally, the nurse applies deeper pressure to feel for any deeper abnormalities in the abdominal organs.
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