The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented?
Ribbon-like stools
Profuse projectile vomiting
Bright red blood and mucus in the stools
Watery diarrhea
The Correct Answer is C
A. Ribbon-like stools
Explanation: Ribbon-like or pencil-thin stools are associated with conditions affecting the rectum, such as colorectal cancer, but they are not a typical sign of intussusception.
B. Profuse projectile vomiting
Explanation: Profuse projectile vomiting is not a typical sign of intussusception. Vomiting may occur, but it is not the primary characteristic feature.
C. Bright red blood and mucus in the stools
Explanation:
Intussusception is a condition in which one part of the intestine slides into another, causing a blockage. One of the classic signs of intussusception is the presence of "currant jelly" stools, which are characterized by a mixture of bright red blood and mucus in the stools. This occurs due to the compression of the blood vessels in the intestine, leading to bleeding and mucosal discharge.
D. Watery diarrhea
Explanation: Watery diarrhea is not a typical sign of intussusception. The condition is more commonly associated with abdominal pain, vomiting, and the characteristic "currant jelly" stools.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["800"]
Explanation
The Parkland formula is commonly used to calculate the fluid requirements for burn resuscitation. The formula is:
Fluid requirement (in mL)=TBSA×Weight (in kg)×Fluid volume (in mL/kg)
For burn patients, the recommended fluid volume is typically 4 mL/kg for each percent of TBSA burned.
Let's calculate the fluid requirement for the given case:
Fluid requirement=40%×22 lbs×4 mL/kg
First, convert the weight from pounds to kilograms:
Weight (in kg)= Weight (in lbs)/2.2
Weight (in kg)=22 lbs/2.2≈10 kg
Now, calculate the fluid requirement:
Fluid requirement=40% x 10 kg × 4 mL/kg
Fluid requirement=1600mL(totalfluidover24hours)
Fluid for the first 8 hours:
1600/2=800ml
Thus, the child will receive 800 mL of fluid in the first 8 hours after the burn injury.
Correct Answer is D
Explanation
A. When a parent is holding the infant
Explanation: Being held by a parent is generally a comforting and calming experience for an infant, and it is unlikely to significantly increase oxygen demand. In fact, the presence of a familiar caregiver may help reduce stress.
B. During sleep
Explanation: During sleep, an infant's oxygen demand may decrease, and oxygen supplementation may not be necessary unless there are specific indications or concerns about oxygen saturation levels.
C. When changing the infant's diapers
Explanation: Changing a diaper is a routine care activity that is not likely to significantly increase oxygen demand. It is not typically associated with stress or increased metabolic activity that would necessitate additional oxygen.
D. When drawing blood for electrolyte level testing
Explanation:
Drawing blood for electrolyte level testing is a potentially stressful procedure that may cause distress and anxiety in the infant. Stress and anxiety can increase the metabolic rate and oxygen demand. In a situation where an infant is already prescribed oxygen as needed for heart failure, additional stressors like blood drawing may necessitate the administration of oxygen to ensure an adequate oxygen supply
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