A nurse is caring for an 18-month-old infant.

Exhibits

The nurse has completed the child's admission assessment.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential condition- Intussusception

Intussusception is a condition where one part of the intestine folds into another part, causing an obstruction. It is common in infants and toddlers and typically presents with the following signs- Severe abdominal pain, which causes the child to pull their knees to their chest (classic sign of colicky abdominal pain), red, jelly-like stools (which indicate the presence of blood and mucus in the stool) and palpable mass in the right upper quadrant (which could be the telescoping portion of the bowel).

Actions to Take

Place child on NPO status:

The child should be placed on nothing by mouth (NPO) status to prepare for potential procedures, such as an enema or surgery. This prevents aspiration during any intervention and ensures the bowel is not further irritated by food or liquid intake.

Prepare child for an air enema:

Air enema is a non-invasive treatment for intussusception. It is often used to reduce the telescoping bowel by using air under fluoroscopic guidance. This treatment can resolve the condition in many cases without the need for surgery. The nurse must ensure the child is properly prepared for this procedure (e.g., ensuring the child is NPO, monitoring vitals, and explaining the procedure to the family).

Parameters to Monitor

Stool patterns:

Monitoring the stool patterns is essential to assess the progress and severity of intussusception. The presence of red, jelly-like stools (blood and mucus) is characteristic of intussusception, and any changes in stool appearance can help evaluate the effectiveness of treatment. The nurse should monitor if the stool pattern changes after the air enema or surgical intervention.

Abdominal pain:

Abdominal pain is a hallmark symptom of intussusception, and the nurse should continually assess the child's pain level. The child may experience intermittent, severe cramp-like pain due to the bowel obstruction. Monitoring and managing the pain effectively is crucial for patient comfort and well-being.

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Correct Answer is C

Explanation

A. Assessing vital signs, including temperature and oxygen saturation, is appropriate for monitoring the child's condition and identifying any signs of respiratory distress or infection.
B. Gathering necessary supplies for possible intubation is a proactive measure in case the child experiences airway obstruction. Acute epiglottitis can lead to rapid deterioration in the child's airway.
C. Assessing the child's throat using a tongue blade can trigger airway obstruction in a child with acute epiglottitis, which is a medical emergency. The throat should not be examined visually due to the risk of causing a spasm or obstruction.
D. Reporting an elevated white blood count is a normal part of managing acute infections, such as epiglottitis, and should be done to inform the healthcare provider of the patient's condition.

A. Allow the child to make decisions about their care within appropriate limits. B. Create a structured daily routine for the child to provide a sense of consistency and security. C. Provide opportunities for the child to express their feelings through drawing or journaling. D. Encourage the child to engage in play activities with other hospitalized children.

Correct Answer is A

Explanation

A. Allowing the child to make decisions about their care helps foster autonomy, which is important in the stage of development described by Erikson for children at this age.
B. While a structured routine is helpful, fostering a sense of independence and decision-making is key to promoting development at this stage.
C. Expressing feelings through creative activities is beneficial but does not address the developmental need for independence and autonomy.
D. Engaging with other children is important for social development, but allowing the child to have some control over their care is essential for psychosocial growth.

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Actions to Take

Parameters to Monitor

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse on a pediatric unit is observing a newly licensed nurse provide care for a child diagnosed with acute epiglottis. Which of the following actions by the newly licensed nurse indicates that the charge nurse should intervene?

Correct Answer is C

Explanation

A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson's theory of psychosocial development?

Correct Answer is A

Explanation

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