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 C
Explanation
The correct answer is choice C. Crohn's disease.
Choice A rationale:
Ulcerative colitis is a chronic inflammatory disease that primarily affects the colon and rectum, causing continuous areas of inflammation and ulcers. It does not involve any part of the GI tract from mouth to anus as stated in the question.
Choice B rationale:
Meckel's diverticulum is a congenital condition where a small pouch forms in the lower part of the small intestine. It is not characterized by a chronic inflammatory process involving various parts of the GI tract.
Choice C rationale:
Crohn's disease is a chronic inflammatory disorder that can affect any part of the gastrointestinal tract from mouth to anus. It commonly causes inflammation, ulceration, and narrowing of the affected segments of the intestines. This inflammation can lead to a range of symptoms including abdominal pain, diarrhea, and weight loss. The question accurately describes Crohn's disease.
Choice D rationale:
Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by abdominal pain or discomfort and changes in bowel habits. It is not associated with chronic inflammatory processes or ulceration as seen in Crohn's disease.
Correct Answer is D
Explanation
The correct answer is choice E. Board games.
Choice A rationale:
Computer games might not be the best choice for a child with osteomyelitis. These games involve prolonged screen time and limited physical movement, which could potentially hinder the child's recovery.
Choice B rationale:
Paper and paints involve a level of physical activity that might not be suitable for a child with osteomyelitis. The child's movement might be restricted due to the condition, and activities that require fine motor skills might not be comfortable for them.
Choice C rationale:
Jack-in-the-box involves sudden surprises and might startle the child, which could be detrimental to their recovery. Children with osteomyelitis might be dealing with pain and discomfort, so it's important to avoid activities that could cause unnecessary distress.
Choice D rationale:
Stuffed animals might be a comforting option for the child. However, the child might also experience pain or discomfort when handling stuffed animals due to their condition. It's better to choose activities that don't involve physical contact that could potentially exacerbate the child's symptoms.
Choice E rationale:
Board games are a suitable choice for a child with osteomyelitis. They provide mental stimulation and entertainment without requiring excessive physical activity. Board games also promote social interaction if played with others, which is important for the child's emotional well-being during their hospital stay.
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