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 C
Explanation
A. A urinary output of 30 mL/hr
Explanation: While decreased urinary output may indicate dehydration, it is not a specific finding related to pertussis. Dehydration can occur due to inadequate fluid intake or loss through vomiting or sweating.
B. A white blood cell (WBC) count of 10,000 mm3 (10×10^9/L)
Explanation: An elevated white blood cell count is a common finding in infections, including pertussis. It reflects the body's immune response to the infection. A WBC count of 10,000 mm3 is within the normal range, and while it indicates an inflammatory response, it does not specifically point to a complication.
C. Decreased breath sounds in the lung bases
Explanation:
Pertussis is a respiratory infection caused by the bacterium Bordetella pertussis. Complications can arise, including pneumonia. Decreased breath sounds in the lung bases may suggest the presence of pneumonia, which is a serious complication of pertussis. Pneumonia can lead to respiratory distress and requires prompt medical attention.
D. A weight gain
Explanation: Weight gain is not typically associated with pertussis. In fact, respiratory distress and difficulty feeding during coughing paroxysms can lead to weight loss in infants with pertussis. Weight gain may be indicative of other unrelated factors.
Correct Answer is C
Explanation
A. Edema in the lower extremities:
Incorrect: Edema in the lower extremities is more characteristic of right-sided heart failure. In left-sided failure, pulmonary congestion is more prominent.
B. Ascites:
Incorrect: Ascites, or fluid accumulation in the abdominal cavity, is also more commonly associated with right-sided heart failure.
C. Shortness of breath:
Correct Answer: Left-sided congestive heart failure can lead to pulmonary congestion, resulting in difficulty breathing or shortness of breath. This is often observed as increased work of breathing, rapid breathing, or other signs of respiratory distress in infants.
D. Hepatomegaly:
Incorrect: Hepatomegaly, or enlargement of the liver, is another manifestation more commonly associated with right-sided heart failure.
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