which of the following is a hallmark sign of intussusception in children
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Nursing Elites

ATI RN

ATI Nursing Care of Children 2019 B

1. Which of the following is a hallmark sign of intussusception in children?

Correct answer: B

Rationale: "Currant jelly" stools, consisting of mucus and blood, are characteristic of intussusception in children. It occurs due to the telescoping of a segment of the intestine into an adjacent segment, leading to obstruction and subsequent mucosal ischemia, causing the passage of bloody mucus in the stool. Bilious vomiting can be seen in other conditions like bowel obstruction, abdominal distention can be present but is not as specific, and constipation is less likely in the presentation of intussusception.

2. Which immunization should the nurse include in a teaching session for parents of toddler-age clients to decrease the risk for epiglottitis?

Correct answer: D

Rationale: The correct answer is D, Hemophilus influenzae type B (Hib) vaccine. Hib vaccine is crucial in preventing epiglottitis, a serious respiratory condition caused by Haemophilus influenzae type b bacteria. This vaccine is recommended for toddlers to protect them from developing epiglottitis. Choices A, B, and C are incorrect because while they are important vaccines for children, they do not specifically target the prevention of epiglottitis, unlike the Hib vaccine.

3. The nurse is teaching parents about the types of behaviors children exhibit when living with chronic violence. Which statement made by the parents indicates further teaching is needed?

Correct answer: C

Rationale: Children exposed to chronic violence may struggle with stress and concentration but are less likely to consistently exhibit caring behaviors without intervention and support.

4. What measure of fluid balance status is most useful in a child with acute glomerulonephritis?

Correct answer: B

Rationale: Daily weight is the most accurate measure of fluid balance in children with acute glomerulonephritis, as it reflects changes in body fluid status more reliably than other measures like proteinuria or specific gravity.

5. The mother of a 3-month-old breastfed infant asks about giving her baby water because it is summer and very warm. What should the nurse tell her?

Correct answer: A

Rationale: Breast milk provides adequate hydration, even in warm weather, so additional fluids like water are not necessary and can interfere with breastfeeding.

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