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 ["A","B","D"]
Explanation
The correct answers are choices A, B, and D.
Choice A rationale:
Decreased urinary output can be a sign of heart failure, especially in infants. In heart failure, the heart's ability to pump effectively can lead to decreased blood flow to the kidneys, resulting in decreased urine production.
Choice B rationale:
Sweating (inappropriate) is a symptom of heart failure in infants. Infants with heart failure might sweat excessively, especially while feeding or crying, due to the effort required by the heart to pump blood effectively.
Choice C rationale:
Warm flushed extremities are not typically associated with heart failure in infants. In heart failure, extremities might actually become cool and pale due to poor circulation.
Choice D rationale:
Anorexia, or a lack of appetite, is a common sign in infants with heart failure. The increased effort required for feeding due to compromised cardiac function can lead to poor feeding and decreased appetite.
Choice E rationale:
Weight loss can occur in infants with heart failure due to inadequate caloric intake, difficulty with feeding, and increased metabolic demands associated with heart failure. However, it's not as specific a sign as decreased urinary output, sweating, and anorexia.
Correct Answer is A
Explanation
The correct answer is Choice A.Choice A rationale:Vomiting is a common sign of digoxin toxicity. It occurs due to the drug's effects on the gastrointestinal system, which can lead to nausea and vomiting as the body attempts to expel the toxin. This symptom is particularly significant as it can indicate elevated digoxin levels that may require medical intervention.Choice B rationale:Tachycardia, or an increased heart rate, can occur with digoxin toxicity; however, it is more commonly associated with inadequate therapeutic levels rather than toxicity itself. Digoxin usually causes bradycardia (a slower heart rate) when at therapeutic levels, making tachycardia less indicative of toxicity.Choice C rationale:Bradypnea, or slow breathing, is not a typical sign of digoxin toxicity. While respiratory issues can arise from various conditions, they are not specifically linked to digoxin levels. Monitoring respiratory rate is essential in clinical settings but does not directly correlate with digoxin toxicity.Choice D rationale:Seizures are not a common sign of digoxin toxicity. While severe cases might lead to neurological symptoms due to electrolyte imbalances or other complications, seizures are not typically associated with digoxin overdose. Instead, they may suggest other underlying issues requiring evaluation.
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