a nurse is caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis hps what is most important for the nurse to assess
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HESI LPN

Pediatric HESI Practice Questions

1. A nurse is caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). What is most important for the nurse to assess?

Correct answer: B

Rationale: The correct answer is B: Signs of dehydration. Infants with hypertrophic pyloric stenosis (HPS) are at high risk of dehydration due to frequent vomiting. Assessing for signs of dehydration, such as decreased urine output, dry mucous membranes, and sunken fontanelles, is crucial for early intervention and management. Choices A, C, and D are not the most critical assessments for HPS. The quality of the cry (choice A) may not provide as much relevant information in this case. Coughing up of feedings (choice C) may be a symptom but is not as crucial as assessing for dehydration. Characteristics of the stool (choice D) are important but assessing for signs of dehydration takes precedence due to the immediate risk it poses to the infant's health.

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

Correct answer: C

Rationale: The correct answer is C: palpable olive-like mass. In pyloric stenosis, a palpable olive-like mass can often be felt in the abdomen due to the hypertrophied pyloric muscle. This mass is a key characteristic finding in infants with pyloric stenosis. Choice A, abdominal rigidity, is more commonly associated with conditions like peritonitis. Choice B, substernal retraction, is not typically seen in pyloric stenosis but can be a sign of respiratory distress. Choice D, marked distention of the lower abdomen, is not specific to pyloric stenosis and can be present in various abdominal conditions.

3. A group of nursing students is reviewing the components of the endocrine system. The students demonstrate understanding of the review when they identify what as the primary function of this system?

Correct answer: B

Rationale: The correct answer is 'Hormonal secretion' (Choice B). The primary function of the endocrine system is to secrete hormones that regulate various bodily functions such as metabolism, growth, and reproduction. Choice A, 'Regulation of water balance,' is primarily controlled by the kidneys and the urinary system, not the endocrine system. Choice C, 'Cellular metabolism,' is more directly related to the functions of individual cells rather than the overall function of the endocrine system. Choice D, 'Growth stimulation,' is a function that can be influenced by hormones secreted by the endocrine system, but it is not the primary function of the system.

4. During a nap, a 3-year-old hospitalized child wets the bed. How should the nurse respond?

Correct answer: C

Rationale: When a 3-year-old hospitalized child wets the bed during a nap, the nurse should respond by changing the child’s clothes without discussing the incident. This approach helps to maintain the child's dignity, avoid embarrassment, and reduce anxiety related to bedwetting. Asking the child to help with remaking the bed (Choice A) may not be appropriate as it could cause unnecessary distress. Putting clean sheets on the bed over a rubber sheet (Choice B) addresses the aftermath but does not directly address the child's needs. Explaining that children should call the nurse when they need to go to the bathroom (Choice D) may not be effective in this immediate situation of bedwetting during a nap.

5. What should be included in the preoperative teaching for a 4-year-old child scheduled for a tonsillectomy?

Correct answer: B

Rationale: Encouraging deep breathing exercises is important preoperative teaching for a child scheduled for a tonsillectomy. Deep breathing exercises can help the child relax and reduce anxiety, which is beneficial before the procedure. Explaining the procedure in detail might be overwhelming for a 4-year-old, whereas encouraging deep breathing exercises can be more beneficial in promoting relaxation and preparing the child. Discussing the importance of hydration is crucial for postoperative care but may not be the priority for preoperative teaching. Using play therapy can help prepare the child, but encouraging deep breathing exercises is more directly related to relaxation and preparation for the procedure.

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