The nurse is caring for a boy with probable intussusception. While waiting for a radiologist-guided pneumonia to visualize and correct the intussusception, the child passes a currant jelly-like stool.
Which nursing action is the most appropriate?
Measure the abdominal girth.
Notify the practitioner as this is not a typical finding.
Document as an expected finding and plan to move forward with the procedure.
Auscultate for bowel sounds.
The Correct Answer is C
Choice A reason:
Measuring the abdominal girth is a useful assessment tool in cases of suspected abdominal distension or fluid accumulation. However, in the context of intussusception, the passage of a currant jelly-like stool is a more critical indicator of the condition. While measuring abdominal girth can provide additional information, it is not the most appropriate immediate action in this scenario.
Choice B reason:
Notifying the practitioner as this is not a typical finding is incorrect because the passage of currant jelly-like stool is a classic symptom of intussusception. This stool appearance results from a mixture of mucus and blood due to the telescoping of the intestine, which compromises blood flow and causes ischemia. Therefore, this finding should be documented as expected rather than considered atypical.
Choice C reason:
Documenting the passage of currant jelly-like stool as an expected finding and planning to move forward with the procedure is the most appropriate action. This stool appearance is a hallmark sign of intussusception, indicating that the condition is present and needs to be addressed promptly. The radiologist-guided pneumoenema is a diagnostic and therapeutic procedure that can help resolve the intussusception by using air pressure to unfold the telescoped segment of the intestine. Therefore, documenting this finding and proceeding with the planned intervention is crucial.
Choice D reason:
Auscultating for bowel sounds is a standard nursing assessment technique to evaluate gastrointestinal function. However, in the context of intussusception, the passage of currant jelly-like stool is a more definitive indicator of the condition. While auscultating for bowel sounds can provide additional information about bowel activity, it is not the most appropriate immediate action in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Bacteriuria, or the presence of bacteria in the urine, is not typically associated with acute glomerulonephritis. Acute glomerulonephritis is primarily an inflammatory condition affecting the glomeruli of the kidneys, and it does not usually involve bacterial infection. Increased specific gravity can occur due to concentrated urine, but bacteriuria is not a characteristic finding.
Choice B reason:
Hematuria, or blood in the urine, and mild to moderate proteinuria are characteristic findings in acute glomerulonephritis. Hematuria occurs due to inflammation and damage to the glomeruli, allowing red blood cells to pass into the urine. Proteinuria results from the increased permeability of the glomerular basement membrane, allowing proteins to leak into the urine. These findings are key indicators of glomerular inflammation and damage.
Choice C reason:
While proteinuria can be present in acute glomerulonephritis, bacteriuria is not a typical finding. The condition is primarily inflammatory rather than infectious, so the presence of bacteria in the urine is not expected. The focus should be on the inflammatory markers such as hematuria and proteinuria.
Choice D reason:
High levels of proteinuria and decreased specific gravity are not typical findings in acute glomerulonephritis. While proteinuria can occur, it is usually mild to moderate rather than high. Specific gravity may be increased due to concentrated urine, but decreased specific gravity is not a characteristic finding of this condition.
Correct Answer is C
Explanation
Choice A reason:
Walnuts are a source of protein and contain phenylalanine, an amino acid that individuals with phenylketonuria (PKU) must limit in their diet. While nuts can be a healthy snack for most people, they are not suitable for those with PKU due to their high phenylalanine content. Therefore, walnuts are not the best choice for children with PKU.
Choice B reason:
Cow’s milk is another source of protein and contains significant amounts of phenylalanine. Dairy products, including milk, cheese, and yogurt, are generally high in protein and should be avoided by individuals with PKU. Consuming cow’s milk can lead to elevated levels of phenylalanine in the blood, which can be harmful to children with PKU.
Choice C reason:
Bananas are a fruit that contains very low levels of phenylalanine. Fruits and vegetables are generally safe for individuals with PKU as they are low in protein and phenylalanine. Bananas, in particular, are a good option for children with PKU as they provide essential nutrients without contributing to high phenylalanine levels.
Choice D reason:
Diet soda with aspartame should be avoided by individuals with PKU because aspartame is an artificial sweetener that contains phenylalanine. Consuming products with aspartame can lead to an increase in phenylalanine levels in the blood, which can be harmful to those with PKU. Therefore, diet soda with aspartame is not a suitable choice for children with PKU.
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