what should the nurse assess in an infant diagnosed with hypertrophic pyloric stenosis

HESI LPN

Nutrition Final Exam Quizlet

1. What should be assessed in an infant diagnosed with hypertrophic pyloric stenosis?

A. Diarrhea after each feeding
B. Gastric pain and vigorous crying
C. Poor appetite due to poor sucking reflex
D. An olive-shaped mass right of the midline

Correct answer: D

Rationale: In hypertrophic pyloric stenosis, an olive-shaped mass can often be palpated in the infant's abdomen, which is a hallmark sign of this condition. This mass is located in the right upper quadrant of the abdomen, right of the midline. Choices A, B, and C are incorrect because while infants with hypertrophic pyloric stenosis may experience vomiting (not diarrhea), gastric pain, and irritability, and have feeding difficulties, the key assessment finding specific to this condition is the palpable olive-shaped mass in the abdomen.

2. Which individual is making a food choice based on negative association?

A. A tourist from China who rejects a hamburger due to unfamiliarity
B. A child who spits out his mashed potatoes because they taste too salty
C. A teenager who grudgingly accepts an offer for an ice cream cone to avoid offending a close friend
D. An elderly gentleman who refuses a peanut butter and jelly sandwich because he considers it a child's food

Correct answer: D

Rationale: Choice D is the correct answer because the elderly gentleman is refusing the peanut butter and jelly sandwich due to his negative association of considering it a child's food. This negative association influences his food choice. Choices A, B, and C do not involve negative associations with the food being consumed. Choice A is based on unfamiliarity, Choice B is due to taste preference, and Choice C is driven by social considerations rather than negative food association.

3. What is critical for preventing complications in an infant with hypothyroidism?

A. Excessive growth
B. Cognitive impairment
C. Damage to the nervous system
D. Damage to the urinary system

Correct answer: B

Rationale: The correct answer is B: Cognitive impairment. In infants with hypothyroidism, prompt administration of oral thyroid hormone replacement is crucial to prevent cognitive impairment and other serious complications. Excessive growth (choice A) is not a typical complication of hypothyroidism in infants. While hypothyroidism can affect the nervous system (choice C), cognitive impairment is more specific to untreated cases. Damage to the urinary system (choice D) is not a common complication of hypothyroidism in infants.

4. What is the priority assessment for a child with suspected appendicitis?

A. Temperature
B. Heart rate
C. Respiratory rate
D. Pain level

Correct answer: D

Rationale: The priority assessment for a child with suspected appendicitis is 'Pain level.' Evaluating the pain level, particularly in the lower right quadrant, is crucial as it helps in determining the severity of the condition, leading to prompt diagnosis and treatment. Monitoring temperature, heart rate, and respiratory rate are important aspects of assessment; however, they are secondary to assessing the pain level in cases of suspected appendicitis. Pain assessment is key in diagnosing this condition since the classic presentation includes abdominal pain that often starts around the umbilicus and then localizes to the right lower quadrant.

5. What is a key aspect of managing a child with cystic fibrosis?

A. Regular pulmonary function tests
B. Daily administration of antibiotics only
C. High-sugar diet
D. Limiting all physical activities

Correct answer: A

Rationale: Regular pulmonary function tests are a key aspect of managing a child with cystic fibrosis. These tests help monitor lung function and disease progression effectively, providing valuable information for healthcare providers to make timely interventions and adjustments to treatment plans. Daily administration of antibiotics alone (Choice B) is important but not the sole key aspect of managing cystic fibrosis. A high-sugar diet (Choice C) is not recommended for individuals with cystic fibrosis as it can exacerbate health issues. Limiting all physical activities (Choice D) is not beneficial as regular exercise is important for overall health and lung function in individuals with cystic fibrosis.