a nurse is assessing a 3 month old infant with suspected pyloric stenosis what clinical manifestation is the nurse likely to observe
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Nursing Elites

HESI LPN

Pediatric HESI 2023

1. A healthcare provider is assessing a 3-month-old infant with suspected pyloric stenosis. What clinical manifestation is the healthcare provider likely to observe?

Correct answer: A

Rationale: Projectile vomiting is a classic clinical manifestation of pyloric stenosis in infants. This occurs due to the narrowing of the pyloric sphincter, leading to the forceful expulsion of gastric contents in a projectile manner. Diarrhea (choice B) is not typically associated with pyloric stenosis. Constipation (choice C) is also not a common symptom of this condition. Abdominal distension (choice D) may occur in pyloric stenosis but is not as specific or characteristic as projectile vomiting in diagnosing this condition.

2. A healthcare professional is teaching parents about why most children should be immunized against varicella (chickenpox) and why some receiving specific medications should not. Which medication should be included in the discussion?

Correct answer: B

Rationale: The correct answer is B: Steroids. Children receiving steroids should not receive the varicella vaccine as it can increase the risk of severe infection due to the immunosuppressive effects of steroids. Insulin (Choice A), antibiotics (Choice C), and anticonvulsants (Choice D) do not interact with the varicella vaccine in the same way as steroids, and therefore, they are not contraindicated.

3. The parents of a child with asthma ask the nurse how they can help their child prevent asthma attacks. What should the nurse advise?

Correct answer: A

Rationale: The correct answer is to advise the parents to avoid exposure to allergens. Asthma attacks are often triggered by allergens such as dust mites, pollen, pet dander, and mold. By minimizing the child's exposure to these triggers, the likelihood of asthma attacks can be reduced. Encouraging regular exercise is beneficial for overall health but may not directly prevent asthma attacks. Providing a high-protein diet and increasing fluid intake are important for general well-being but do not specifically address asthma prevention.

4. What is the priority nursing intervention for a child with a diagnosis of acute lymphoblastic leukemia (ALL) receiving chemotherapy?

Correct answer: A

Rationale: The correct answer is A: Preventing infection. When caring for a child with acute lymphoblastic leukemia (ALL) undergoing chemotherapy, the top priority is to prevent infection. Chemotherapy suppresses the immune system, making the child more susceptible to infections. By implementing infection control measures such as hand hygiene, aseptic techniques, and environmental cleanliness, the nurse can help protect the child from potentially life-threatening infections. Administering chemotherapy (choice B) is important but not the priority over preventing infection. Providing nutritional support (choice C) and monitoring fluid intake (choice D) are essential aspects of care but take a back seat to preventing infection in this scenario.

5. What should the nurse include in the care plan for a 6-month-old infant admitted with a diagnosis of respiratory syncytial virus (RSV)?

Correct answer: D

Rationale: Elevating the head of the bed is crucial in the care plan for an infant with RSV as it helps improve breathing by facilitating better airflow and drainage of secretions. This position can also enhance comfort and reduce respiratory distress. Providing small, frequent feedings (Choice A) is generally beneficial for infants but is not specific to managing RSV. Administering antibiotics (Choice B) is not indicated for RSV as it is caused by a virus, and antibiotics are ineffective against viral infections. Maintaining strict isolation (Choice C) is important to prevent the spread of contagious infections but is not a direct intervention for improving the infant's respiratory status in RSV.

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