A one-month old male infant is brought to the clinic by his mother who states that her son has been vomiting forcefully after each meal for the last three days. The infant is afebrile, dehydrated, and pyloric stenosis is suspected. Which other findings should the nurse identify that are consistent with pyloric stenosis?

Rooting, hunger, and irritability.

An olive-shaped mass in the abdominal area.

Bile-stained emesis.

Perianal diaper rash from persistent diarrhea

Answer and Explanation

The Correct Answer is B

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Correct Answer is C

Explanation

A.While non-pharmacologic strategies are important for pain management, they are typically introduced after initial assessment and understanding of the client's pain experience. In this case, the priority is to clarify the apparent discrepancy between the reported pain level and observed behavior.

B.Respecting the client's privacy and providing time for personal activities like phone calls is important but does not directly address the concern of incongruent pain assessment and behavior.

C.Incongruence between reported pain intensity (10/10) and observed behavior (laughing on the phone) suggests a potential discrepancy that needs to be documented and further investigated. This documentation is crucial for accurate assessment and communication among the healthcare team.

D.Administering pain medication immediately without further assessment may not be appropriate if there is uncertainty about the accuracy of the pain report. It's important to first clarify and validate the client's pain experience before proceeding with medication administration.

A. Calcium acetate. B. Albuterol inhaler. C. Pancreatic enzymes. D. Empiric antibiotics.

Correct Answer is C

Explanation

A.Calcium acetate is not a standard medication that needs to be given with every meal for children with cystic fibrosis.

B.An albuterol inhaler is used for managing respiratory symptoms, such as bronchoconstriction and wheezing. It's not typically administered with every meal.

C.Pancreatic enzymes are the appropriate medication. Children with cystic fibrosis often have pancreatic insufficiency, which means their pancreas doesn't produce enough enzymes needed for proper digestion. Pancreatic enzyme replacement therapy is essential for these children to help them digest and absorb nutrients from their food. These enzymes should be administered with every meal to ensure effective digestion.

D.Empiric antibiotics are prescribed based on clinical indications and infection status. They are not routinely given with every meal.

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Naxlex Comprehensive Predictor Exams

An adolescent hospitalized with sickle cell anaemia reports to the nurse of experiencing a pain level of 10 on a 0 to 10 numerical scale. The nurse observes the adolescent on a phone call laughing. Which action should the nurse take?

Correct Answer is C

Explanation

The nurse is caring for a school-age child with cystic fibrosis and reviews the admission medication prescriptions. Which medication should the nurse obtain a prescription for to be administered with every meal?

Correct Answer is C

Explanation

The nurse is planning care for a 4-year-old girl who is diagnosed as having a developmental disability. What should be the primary focus of treatment for this child?

One week after removing a tick that bit him, a student arrives at the school nurse's office with reports of flu-like symptoms. Which intervention should the school nurse implement first?

The nurse is admitting a child with a diagnosis of untreated hypoparathyroidism. Which finding indicative of hypocalcaemia should the nurse report to the healthcare provider?

A healthy 2-day-old newborn received the first dose of hepatitis B prior to being discharge home with the parents. The nurse should instruct the parents to return to the clinic for the infant's next dose of hepatitis B in how many months?

How should the nurse instruct the parents of a 4-month-old with seborrheic dermatitis (cradle cap) to shampoo the child's hair?

A 15-year-old girl asks the clinic nurse for information about oral contraceptives because she is planning to have sexual relations with her 17- year-old boyfriend but does not want her parents to know. Which action should the nurse take?

The nurse is providing education to a new parent on the potential causes of developmental dysplasia of the hip and recommendations to decrease the incidence in infants. Which statement made by the parent should the nurse recognize as understanding the education?