Which of these assessments is the priority for an infant who is diagnosed with Hirschsprung disease?
Total white blood cell count 7,000/mm.
Serum potassium 4.2 mEq/L.
Nonbilious vomiting.
Watery diarrhea.
The Correct Answer is C
Choice A rationale:
While monitoring the total white blood cell count is important, it is not the priority assessment for a child with Hirschsprung disease. The disease primarily affects the gastrointestinal system.
Choice B rationale:
Serum potassium level within the normal range (4.2 mEq/L) is relevant, but it doesn't take precedence over assessing symptoms directly related to Hirschsprung disease.
Choice C rationale:
Nonbilious vomiting could indicate a bowel obstruction, a potential complication of Hirschsprung disease. Prompt assessment is necessary to prevent further complications.
Choice D rationale:
Watery diarrhea might occur in Hirschsprung disease, but it's not as urgent as addressing vomiting, which could indicate a more immediate problem like bowel obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Avoid setting limits or establishing disciplinary guidelines is not appropriate. Children with cognitive impairment require structure and consistent boundaries to ensure their safety and development.
Choice B rationale:
Encouraging the child to socialize with same-aged children is important for their social and emotional development. Interaction with peers fosters communication skills and helps them integrate into society.
Choice C rationale:
Avoid discussing sexuality until the child is an adult may lead to misinformation and confusion. Addressing sexuality in an age-appropriate manner is vital to help the child develop a healthy understanding of their body and relationships.
Choice D rationale:
Encouraging delaying the child's entry into educational programs hinders their cognitive and intellectual growth. Early intervention and tailored educational programs are crucial for children with cognitive impairment to reach their full potential.
Correct Answer is C
Explanation
Remove all beverages from the patient's bedside.
Choice A rationale:
Giving the patient a laxative is inappropriate and unnecessary in the context of a ruptured appendix. The focus should be on preparing the patient for surgery and managing the acute condition.
Choice B rationale:
Administering ibuprofen should be avoided as it can mask symptoms and potentially worsen the patient's condition by masking signs of inflammation or infection. This delay in appropriate care could lead to complications.
Choice C rationale:
Removing all beverages from the patient's bedside is essential. NPO (nothing by mouth) status is typically maintained for patients with suspected appendicitis or other surgical conditions to prevent potential aspiration in case surgery is required.
Choice D rationale:
Providing a heating pad is contraindicated in cases of suspected appendicitis or any acute abdominal condition. Heat can worsen inflammation and potentially cause the appendix to rupture, leading to more severe complications.
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