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. While assessing a child admitted for an asthma attack, a nurse in the emergency department observes large welts and scars on the child's back. What additional information must be included in the nurse’s assessment?

Correct answer: B

Rationale: The correct answer is B: Signs of child abuse. When a nurse observes large welts and scars on a child, it raises concern for possible child abuse. It is crucial for the nurse to assess further for signs of abuse, document findings, and report appropriately to protect the child. Choice A, history of an injury, is not specific to potential abuse and may not provide insight into the current situation. Choice C, presence of food allergies, is not directly related to the observed welts and scars. Choice D, recent recovery from chickenpox, is also unrelated to the signs of abuse and does not impact the immediate assessment of the child's safety.

3. A child with a diagnosis of asthma is being evaluated for medication management. What is an important assessment for the nurse to perform?

Correct answer: B

Rationale: Assessing the child's dietary intake is crucial in managing asthma as certain foods can trigger symptoms or exacerbate the condition. By evaluating the child's diet, the nurse can identify potential triggers, ensure the child receives proper nutrition, and help manage symptoms effectively. Assessing sleep patterns, academic performance, or behavior at home, while important in a holistic assessment, are not as directly related to managing asthma symptoms as dietary intake.

4. Your assessment of a mother in active labor reveals that a limb is protruding from the vagina. Management of this condition should include:

Correct answer: B

Rationale: In a situation where a limb is protruding from the vagina during active labor, the correct management includes positioning the mother in a head-down position with her hips elevated. This position helps relieve pressure on the umbilical cord and improves oxygenation to the fetus. Administering oxygen is important to ensure adequate oxygen supply to both the mother and the baby. Providing transport is necessary for prompt transfer to a medical facility for further management. Applying gentle traction to the protruding limb is not recommended as it can cause harm to the baby and should be avoided. Giving 100% oxygen and attempting to manipulate the protruding limb is not the correct approach and can potentially lead to further complications.

5. Which observation of the exposed abdomen is most indicative of pyloric stenosis?

Correct answer: C

Rationale: In pyloric stenosis, a palpable olive-like mass in the abdomen is a classic finding. This mass is due to the hypertrophied pyloric muscle. Abdominal rigidity (choice A) is associated with conditions like peritonitis, substernal retraction (choice B) is typically seen in respiratory distress, and marked distention of the lower abdomen (choice D) is more characteristic of conditions like intestinal obstruction rather than pyloric stenosis.

Similar Questions

A nurse is providing care to a child diagnosed with sickle cell anemia. What is the priority nursing intervention?
A newborn is diagnosed with metatarsus adductus. The parents ask the nurse how this occurred. Which response by the nurse would be most appropriate?
A nurse is assessing a child with suspected rheumatic fever. What clinical manifestation is the nurse likely to observe?
A 1-year-old child has a congenital cardiac malformation that causes right-to-left shunting of blood through the heart. What clinical finding should the healthcare provider expect?
A nurse plans to talk to the parents of a toddler about toilet training. What should the nurse explain is the most important factor in the process of toilet training?

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