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
The Correct Answer is B
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
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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