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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer is: d. Apply direct pressure above the catheterization site.
Explanation: The first action should be to apply direct pressure above the catheterization site to help control the bleeding and minimize blood loss. This will also give the nurse time to prepare additional interventions or supplies if necessary.
Choice a. is wrong because placing the child in the Trendelenburg position is not an appropriate initial nursing action in this scenario. This position can increase intracranial pressure and is typically used for patients experiencing shock or hypotension.
Choice b. is wrong because applying a new bandage with more pressure might be a subsequent action, but the priority is to apply direct pressure to slow down the bleeding.
Choice c. is wrong because notifying the physician is important, but the nurse should first take immediate action to control the bleeding and minimize potential harm to the patient.
Correct Answer is D
Explanation
The correct answer is choice D. It is a belief common at this age.
Choice A rationale:
The statement does not suggest a failed attempt to develop a conscience. The scenario described is more related to the cognitive development of an 8-year-old child. Children at this age often have magical thinking and may interpret events, such as illness, as punishments for perceived wrongdoing. This is a normal aspect of their cognitive development rather than a reflection of a failed attempt to develop a conscience.
Choice B rationale:
While beliefs about punishment and consequences are present in many religions, the scenario is not about a general religious belief but rather a specific belief held by the individual child. This belief is reflective of the child's cognitive understanding and not necessarily a religious teaching common to most religions.
Choice C rationale:
The belief is not necessarily suggestive of excessive family pressure. While family dynamics can influence a child's beliefs and behaviors, the scenario describes a typical cognitive developmental stage where children are still learning to differentiate between reality and their own thoughts, leading to magical thinking and unique interpretations.
Choice D rationale:
The belief is indeed common at this age. During middle childhood, children often exhibit concrete operational thinking, which includes a tendency to interpret events in a self-centered and concrete manner. Beliefs like the one described in the scenario, where the child connects her illness to perceived bad behavior and potential consequences, are characteristic of this developmental stage.
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