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 A
Explanation
A. Heat intolerance
Explanation:
Graves' disease is an autoimmune disorder that results in hyperthyroidism, meaning there is an overproduction of thyroid hormones. Common symptoms of Graves' disease include heat intolerance, increased sweating, weight loss, palpitations, and anxiety. The hyperactivity of the thyroid gland leads to an increased metabolic rate, causing heat intolerance.
B. Bradycardia
Explanation: Bradycardia (slow heart rate) is not typically associated with Graves' disease. Hyperthyroidism usually leads to an increased heart rate (tachycardia) due to the stimulatory effects of thyroid hormones on the cardiovascular system.
C. Lethargy
Explanation: Lethargy (excessive tiredness or lack of energy) is more commonly associated with hypothyroidism, where there is an insufficient production of thyroid hormones. In Graves' disease, the excess thyroid hormones often lead to symptoms of hyperactivity, not lethargy.
D. Weight gain
Explanation: Weight gain is not a typical finding in Graves' disease. Hyperthyroidism often leads to unintentional weight loss due to increased metabolism and energy expenditure. Weight gain is more commonly associated with hypothyroidism.
Correct Answer is ["90"]
Explanation
The nurse should withhold the dose if the infant's apical heart rate is less than 90 beats per minute.
Digoxin is a medication that can slow the heart rate. If an infant's heart rate is already too slow, administering digoxin can increase the risk of bradycardia, a serious heart rhythm disturbance.
It's important to monitor the apical heart rate for a full minute before administering digoxin to an infant and to withhold the dose if the heart rate is below the specified threshold.
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