a nurse is assessing a child with suspected intussusception what clinical manifestation is the nurse likely to observe
Logo

Nursing Elites

HESI LPN

HESI Pediatrics Quizlet

1. A child is being assessed for suspected intussusception. What clinical manifestation is the nurse likely to observe?

Correct answer: C

Rationale: The correct clinical manifestation that a nurse is likely to observe in a child with suspected intussusception is abdominal distension. Intussusception is a medical emergency where a part of the intestine folds into itself, causing obstruction. Abdominal distension is a common symptom due to the obstruction and the build-up of gases and fluids. While currant jelly stools (Choice B) are a classic sign of intussusception, they are typically seen in later stages of the condition and may not be present during the initial assessment. Projectile vomiting (Choice A) is more commonly associated with conditions like pyloric stenosis. Constipation (Choice D) is not a typical manifestation of intussusception; the condition usually presents with severe colicky abdominal pain and possible passage of blood and mucus in stools.

2. Why should a nurse plan an evening snack for a child receiving Novolin N insulin?

Correct answer: D

Rationale: The correct answer is D. Novolin N insulin peaks in the evening, which can lead to hypoglycemia during the night. Providing an evening snack helps to counteract the late insulin activity and prevent hypoglycemia. Choice A is incorrect because the primary reason for the evening snack is not to encourage adherence to the diet. Choice B is incorrect as the snack is not primarily for immediate energy use. Choice C is incorrect as the goal of the snack is not to help the child gain weight but to manage blood sugar levels.

3. The parents of a child who is scheduled for open-heart surgery ask why their child must be subjected to chest tubes after surgery. What should the nurse consider before responding in language the parents will understand?

Correct answer: B

Rationale: Chest tubes are necessary after open-heart surgery to facilitate the drainage of air and fluid from the chest cavity. These tubes help prevent complications such as pneumothorax (accumulation of air in the pleural space) or cardiac tamponade (build-up of fluid in the pericardial sac), which can be serious postoperative issues. Options A, C, and D are incorrect because chest tubes are primarily used for draining purposes and not for increasing tidal volumes, maintaining positive intrapleural pressure, or regulating pressure on the pericardium and chest wall.

4. A parent tells a nurse at the clinic, 'Each morning I offer my 24-month-old child juice, and all I hear is ‘No.’ What should I do because I know my child needs fluid?' What strategy should the nurse suggest?

Correct answer: A

Rationale: Offering a choice between two options allows the child to feel a sense of control while ensuring they get the necessary fluids. Providing a choice empowers the child and increases the likelihood of cooperation. Distracting the child with food or offering the glass in a firm manner may not address the underlying issue of refusal. Allowing the child to witness the parent's anger can create a negative environment and may not help in resolving the situation positively.

5. The school nurse is caring for a boy with hemophilia who fell on his arm during recess. What supportive measures should the nurse use until factor replacement therapy can be instituted?

Correct answer: C

Rationale: The correct supportive measure for the school nurse to use for a boy with hemophilia who fell on his arm during recess is to elevate the area above the level of the heart. Elevating the affected area helps reduce bleeding and swelling in a child with hemophilia until factor replacement therapy can be provided. Applying warm, moist compresses (Choice A) may worsen bleeding by dilating blood vessels. Applying pressure for at least 1 minute (Choice B) is not recommended for hemophilia as it can lead to increased bleeding. Beginning passive range-of-motion (Choice D) should be avoided as it can exacerbate bleeding and further injury in a child with hemophilia.

Similar Questions

An order is written for an isotonic enema for a 2-year-old child. What is the maximum amount of fluid the nurse should administer without a specific order from the healthcare provider?
A 4-year-old child is brought to the emergency department with a suspected fracture. What is the priority nursing action?
A child is being assessed for suspected appendicitis. What clinical manifestation is the healthcare professional likely to observe?
The parents of a 6-month-old infant are concerned about the risk of sudden infant death syndrome (SIDS). What should the nurse recommend to reduce the risk?
A 3-year-old child is being discharged after being treated for dehydration. What should the nurse include in the discharge teaching?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses