What is the most appropriate nursing action when a child with a probable intussusception has a normal, brown stool?
Take vital signs, including blood pressure.
Auscultate for bowel sounds.
Measure abdominal girth.
Notify the practitioner.
The Correct Answer is C
The correct answer is Choice C: Measure abdominal girth.
Choice A rationale:
Taking vital signs, including blood pressure, is important in assessing the overall health status of a child, but it might not provide specific information about a probable intussusception. Blood pressure is not typically affected in a way that directly relates to intussusception.
Choice B rationale:
Auscultating for bowel sounds is an important assessment technique in various gastrointestinal conditions, but it may not be the most appropriate immediate action when dealing with a probable intussusception. While bowel sounds might be diminished or absent in intussusception, the priority should be on assessing other signs and symptoms.
Choice C rationale:
Measuring abdominal girth is an essential nursing action when a child with a probable intussusception has a normal, brown stool. Intussusception is the telescoping of one segment of the intestine into another, often leading to bowel obstruction. Abdominal distension or girth measurement can provide valuable information about the progression of the condition and potential obstruction.
Choice D rationale:
Notifying the practitioner is an important step, but it might not be the most immediate action required. Assessing and monitoring the child's condition should be the initial response to gather more information before notifying the practitioner.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy.
Choice A rationale:
Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy. This choice is incorrect because it includes "aortic hypertrophy" and "left ventricular hypertrophy," which are not components of the tetralogy of Fallot. Aortic hypertrophy is not a recognized structural defect in tetralogy of Fallot, and left ventricular hypertrophy is not a characteristic feature of this congenital heart condition.
Choice B rationale:
Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy. This is the correct choice. Tetralogy of Fallot is characterized by four specific structural defects: pulmonic stenosis (narrowing of the pulmonary valve), ventricular septal defect (hole between the right and left ventricles), overriding aorta (aorta positioned over the ventricular septal defect, receiving blood from both ventricles), and right ventricular hypertrophy (enlargement of the right ventricle due to increased workload).
Choice C rationale:
Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy. This choice is incorrect because it includes "aortic stenosis," which is not part of the tetralogy of Fallot. In tetralogy of Fallot, the stenosis occurs at the pulmonary valve, not the aortic valve.
Choice D rationale:
Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy. This choice is incorrect. While "overriding aorta" is present in tetralogy of Fallot, "atrial septal defect" and "left ventricular hypertrophy" are not part of this condition. Atrial septal defects involve a hole between the two atria, not the ventricles, and left ventricular hypertrophy is not typically seen in tetralogy of Fallot.
Correct Answer is ["A","D","E"]
Explanation
The correct answers are choices A, D, and E. Unequal waist angles, an uneven hemline, and asymmetry of the shoulders.
Choice A rationale:
Unequal waist angles can be an indication of scoliosis, a condition characterized by abnormal lateral curvature of the spine. When the spine curves, it can cause one side of the waist to appear higher than the other, leading to unequal waist angles. This is a key physical finding in scoliosis assessment.
Choice B rationale:
Complaints of a sore back are a non-specific symptom and may not directly indicate scoliosis. While scoliosis can sometimes cause discomfort or pain, it's not the primary assessment finding that the nurse should expect to observe.
Choice C rationale:
Inability to bend at the waist is not a typical assessment finding of scoliosis. Scoliosis primarily involves the lateral curvature of the spine, which can lead to visible asymmetry and postural changes rather than restrictions in bending.
Choice D rationale:
An uneven hemline can be a sign of scoliosis. When the spine curves, it can cause the hips and shoulders to become misaligned, leading to changes in the alignment of clothing and accessories, such as an uneven hemline.
Choice E rationale:
Asymmetry of the shoulders is a common manifestation of scoliosis. One shoulder may appear higher than the other due to the lateral curvature of the spine. This asymmetry is often more noticeable when the child is viewed from behind.
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