What is the most appropriate nursing action when a child with a probable intussusception has a normal, brown stool?

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.

The correct answer is choice D: Verbalizing the importance of monitoring for medication side effects.

Choice A rationale:

Allowing the adolescent to make decisions about whether or not to take medication is important, but it is not the priority nursing goal for a 14-year-old diagnosed with Graves' disease. The priority is ensuring proper medication management and monitoring to control the thyroid dysfunction and prevent potential complications.

Choice B rationale:

Relieving constipation might be a consideration, but it is not the priority nursing goal for a 14-year-old diagnosed with Graves' disease. The primary focus is on addressing the thyroid-related issues and providing appropriate education and support to the adolescent.

Choice C rationale:

Developing alternative educational goals is not the priority nursing goal for a 14-year-old diagnosed with Graves' disease. While education is important, the immediate concern is managing the medical condition and ensuring the adolescent's well-being.

Choice D rationale:

Verbalizing the importance of monitoring for medication side effects is the priority nursing goal for a 14-year-old diagnosed with Graves' disease. Graves' disease is a thyroid disorder that requires medication management, typically involving antithyroid medications or other interventions. Monitoring for medication side effects ensures the adolescent's safety and helps to prevent adverse reactions or complications. It also empowers the adolescent to be vigilant about their health and medication regimen.