A nurse is reinforcing teaching with a parent of a 1 month old infant who is to undergo the initial surgery to treat Hirschsprung’s disease. Which of the following statements should indicate to the nurse that the parent understands the goal of the surgery.
“The operation will straighten out the kink in then intestine.”
“I want to learn how to use the feeding tube as soon as possible.”
“I’m glad my child will have bowel movements now.”
“I’m glad that the ostomy is only temporary.”
The Correct Answer is D
A. "The operation will straighten out the kink in the intestine.": Hirschsprung’s disease involves a lack of nerve cells in the colon, not a physical kink.
B. "I want to learn how to use the feeding tube as soon as possible.": Feeding tubes are not a standard part of treatment for Hirschsprung’s disease.
C. "I’m glad my child will have bowel movements now.": While the surgery will help bowel function, the initial goal is creating an ostomy to divert stool.
D. "I’m glad that the ostomy is only temporary.": The initial surgery often involves a temporary ostomy to allow the colon to heal before definitive repair.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Educate the parents about potential complications: While education is important, it is not the immediate priority.
B. Maintain a saline lock: Maintaining IV access is essential but does not directly address fluid balance, the primary concern.
C. Place the child on a no-salt-added diet: While reducing salt helps control edema, daily weight monitoring is more immediate for assessing fluid retention.
D. Check the child's weight daily: Monitoring weight is the most sensitive indicator of fluid retention and is crucial for evaluating the child's response to treatment.
Correct Answer is C
Explanation
A. Orally: Oral temperature measurement is generally not suitable for a 1-year-old because they are often not able to cooperate, but it is not contraindicated for the child.
B. Tympanic: Tympanic (ear) temperature measurement is acceptable in children over 3 months old and is non-invasive.
C. Rectal: Rectal temperature should be avoided in infants and toddlers with diarrhea due to the risk of rectal trauma and infection. Diarrhea may also cause irritation to the rectal area, increasing the risk of injury.
D. Axillary: Axillary (underarm) temperature measurement is safe and commonly used in children, particularly for non-invasive monitoring.
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