Download NCLEX-Pediatrics: Gastrointestinal Disorders Guide and more Exams Nursing in PDF only on Docsity!
questions and answers
A mother of an infant diagnosed with Hirschsprung's disease asks the nurse about the disorder. The nurse plans to base the response on which information? 1.It is a complete small intestinal obstruction. 2.It is a congenital aganglionosis or megacolon. 3.It is a severe inflammation of the gastrointestinal tract. 4.It is a condition that causes the pyloric valve to remain open. - correct answer ✅2.It is a congenital aganglionosis or megacolon. Hirschsprung's disease, also known as "congenital aganglionosis" or "megacolon," is the result of an absence of ganglion cells in the rectum and to varying degrees upward in the colon. Options 1, 3, and 4 are incorrect. An infant returns to the nursing unit following surgery for an esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous (IV) fluids, and a gastrostomy tube is in place. The nurse assisting in caring for the infant should ensure that which action is done to the gastrostomy tube? 1.Elevated 2.Placed to gravity 3.Attached to low suction 4.Taped to the bed linens - correct answer ✅1.Elevated In the immediate postoperative period, the gastrostomy tube is elevated, allowing gastric contents to pass to the small intestine and air to escape. This promotes
questions and answers
comfort and decreases the risk of leakage at the anastomosis. Options 2, 3, and 4 are incorrect The nurse prepares to administer a pancreatic enzyme powder to the child with cystic fibrosis (CF). Which food item should the nurse mix with the medication? 1.Tapioca 2.Applesauce 3.Hot oatmeal 4.Mashed potatoes - correct answer ✅2.Applesauce Pancreatic enzyme powders are not to be mixed with hot foods or foods containing tapioca or other starches. Enzyme powder should be mixed with nonfat, nonprotein foods such as applesauce. Pancreatic enzymes are inactivated by heat and are partially degraded by gastric acids. The nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data should the nurse expect to note as having been documented in the child's record? 1.Watery diarrhea 2.Projectile vomiting 3.Increased urine output 4.Vomiting large amounts of bile - correct answer ✅2.Projectile vomiting
questions and answers
4.The membranes in the ear canal - correct answer ✅1.The mucous membranes Jaundice, if present, is best checked in the sclera, nail beds, and mucous membranes. Generalized jaundice will appear in the skin throughout the body. Option 4 is not an appropriate assessment area for the presence of jaundice. The nurse is monitoring a newborn with a suspected diagnosis of imperforate anus. Which assessment finding is unassociated with this diagnosis? 1.The presence of stool in the urine 2.Failure to pass a rectal thermometer 3.The passage of currant jelly-like stool 4.Failure to pass meconium in the first 24 hours after birth - correct answer ✅3.The passage of currant jelly-like stool During the newborn assessment, imperforate anus should be easily identified visually. However, a rectal thermometer or tube may be necessary to determine patency if meconium is not passed in the first 24 hours after birth. The presence of stool in the urine or vagina should be reported immediately as an indication of abnormal anorectal development. Currant jelly-like stool is not a symptom of this disorder. The nurse is caring for an infant with a diagnosis of Hirschsprung's disease. The nurse should check for which clinical findings that are consistent with Hirschsprung's disease? Select all that apply.
questions and answers
1.Fever 2.Constipation 3.Failure to thrive 4.Intolerance to wheat 5.Abdominal distention 6.Explosive, watery diarrhea - correct answer ✅1.Fever 2.Constipation 3.Failure to thrive 5.Abdominal distention 6.Explosive, watery diarrhea Clinical symptoms of Hirschsprung's disease during infancy include failure to thrive, constipation, abdominal distention, episodes of diarrhea and vomiting, signs of enterocolitis, explosive and watery diarrhea, and fever. The infant appears significantly ill. Intolerance to wheat occurs in celiac disease. A 2-year-old child is diagnosed with constipation due to encopresis. Which description is a characteristic of this disorder? 1.Anorexia in the evening 2.Incomplete development of the anus 3.The infrequent and difficult passage of dry stools 4.Invagination of a section of the intestine into the distal bowel - correct answer ✅3.The infrequent and difficult passage of dry stools
questions and answers
2.Ribbon-like stools 3.Increased heart rate 4.Hypoactive bowel sounds 5.Profuse projectile vomiting 6.Change in the level of consciousness - correct answer ✅1.Fever 3.Increased heart rate 6.Change in the level of consciousness The child with intussusception classically presents with severe abdominal pain that is crampy and intermittent and that causes the child to draw in his or her knees to the chest. The signs of perforation and shock are evidenced by fever, an increased heart rate, a change in the level of consciousness or blood pressure, and respiratory distress and need to be reported immediately. The options for hypoactive bowel sounds, profuse projectile vomiting, and ribbon-like stools are a part of the presentation picture of a child with intussusception but are not signs of shock. The nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided? 1.Rectal 2.Axillary 3.Electronic 4.Tympanic - correct answer ✅1.Rectal
questions and answers
Rectal temperature measurements should be avoided if diarrhea is present. The use of a rectal thermometer can stimulate peristalsis and cause more diarrhea. Axillary or tympanic measurements of temperature would be acceptable. Most measurements are performed via electronic devices. The nurse is reviewing the health record of an infant with a diagnosis of gastroesophageal reflux. Which signs/symptoms of this disorder should the nurse expect to note documented in the record? 1.Excessive oral secretions 2.Bowel sounds heard over the chest 3.Hiccupping and spitting up after a meal 4.Coughing, wheezing, and short periods of apnea - correct answer ✅3.Hiccupping and spitting up after a meal Clinical manifestations of all types of gastroesophageal reflux include vomiting (spitting up) after a meal, hiccupping, and recurrent otitis media related to pooled secretions in the nasopharynx during sleep. Option 1 is a clinical manifestation of esophageal atresia and tracheoesophageal fistula. Option 2 is a clinical manifestation of congenital diaphragmatic hernia. Option 4 is a clinical manifestation of hiatal hernia. The nurse is reviewing the postoperative primary health care provider's (PHCP'S) prescriptions for a 3-week-old infant with Hirschsprung's disease admitted to the hospital for surgery. Which prescriptions documented in the child's record should the nurse question? Select all that apply.
questions and answers
The nurse reinforces home care instructions to the parents of an infant following surgical intervention for imperforate anus and tells the parents about the procedure for anal dilation. Which statement by the parents indicates the need for further teaching? 1."I need to use a water-soluble lubricant." 2."I will insert a glycerin suppository before the dilation." 3."I will insert the dilator no more than 1 to 2 cm into the anus." 4."I need to use only dilators supplied by the primary health care provider." - correct answer ✅2."I will insert a glycerin suppository before the dilation." Following this surgery, anal dilation at home by the parents is necessary to achieve and maintain bowel patency. Inserting a glycerin suppository before dilation is not a component of this procedure. Options 1, 3, and 4 are accurate instructions and will prevent damage to the rectal mucosa. The nurse provides feeding instructions to a mother of an infant diagnosed with gastroesophageal reflux (GER). To assist in reducing the episodes of emesis, which instruction should the nurse provide the mother 1.Provide less frequent, larger feedings. 2.Burp less frequently during feedings. 3.Thin the feedings by adding water to the formula. 4.Thicken the feedings by adding rice cereal to the formula. - correct answer ✅4.Thicken the feedings by adding rice cereal to the formula.
questions and answers
Small, more frequent feedings with frequent burping are often tried as the first line of treatment in gastroesophageal reflux. Feedings thickened with rice cereal may reduce episodes of emesis. However, thickened feedings do not affect reflux time. If thickened formula is prescribed, 1 to 3 teaspoons of rice cereal per ounce of formula is most commonly used and may require cross-cutting the nipple. Options 1, 2, and 3 are incorrect. The nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child and the prevention of the transmission of the virus. Which statement by a parent indicates a need for further teaching? 1."Frequent hand washing is important." 2."I need to provide a well-balanced, high-fat diet to my child." 3."I need to clean contaminated household surfaces with bleach." 4."Diapers should not be changed near any surfaces that are used to prepare food." - correct answer ✅2."I need to provide a well-balanced, high-fat diet to my child." The child with hepatitis should consume a well-balanced, low-fat diet to allow the liver to rest. Options 1, 3, and 4 are components of the homecare instructions to the family of a child with hepatitis. The nurse provides instructions to the parents of an infant with gastroesophageal reflux (GER) regarding proper positioning to manage reflux. The nurse should tell the parents that the infant should be maintained in which position? 1.A 30-degree angle when supine
questions and answers
alleviates the fears of the child is option 2. Options 1, 3, and 4 do not address the fears and anxieties of the mother and child. The nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely manifestation of this condition in the medical record? 1.Incessant crying 2.Coughing at nighttime 3.Choking with feedings 4.Severe projectile vomiting - correct answer ✅3.Choking with feedings Any child who exhibits the "3 Cs"—coughing and choking during feedings and unexplained cyanosis—should be suspected of having TEF. Options 1, 2, and 4 are not specifically associated with TEF. The nurse is preparing to feed a 1-year-old hospitalized child. The nurse prepares the amount of formula to be given to this child, knowing that generally a 1-year- old consumes approximately which amount? 1.90 mL per feeding 2.100 mL per feeding 3.175 mL per feeding 4.380 mL per feeding - correct answer ✅3.175 mL per feeding
questions and answers
A 1-year-old child consumes approximately 175 mL (6 ounces) of formula per feeding. Options 1, 2, and 4 are incorrect. A newborn infant is diagnosed with gastroesophageal reflux (GER). The mother of the infant asks the nurse to explain the diagnosis. The nurse plans to base the response on which description of this disorder? 1.Gastric contents regurgitate back into the esophagus. 2.The esophagus terminates before it reaches the stomach. 3.Abdominal contents herniate through an opening of the diaphragm. 4.A portion of the stomach protrudes through the esophageal hiatus of the diaphragm. - correct answer ✅1.Gastric contents regurgitate back into the esophagus. Gastroesophageal reflux is regurgitation of gastric contents back into the esophagus. Option 2 describes esophageal atresia. Option 3 describes a congenital diaphragmatic hernia. Option 4 describes a hiatal hernia The nurse is assisting in admitting to the hospital a 4-month-old infant with a diagnosis of vomiting and dehydration. The nurse assists in developing a plan of care for the infant and suggests which position for the infant? 1.Prone position 2.Side-lying position 3.Modified Trendelenburg's position
questions and answers
The nurse is assigned to assist in caring for a newborn with a colostomy that was created during surgical intervention for imperforate anus. When the newborn returns from surgery, the nurse checks the stoma and notes that it is red and edematous. Which is the appropriate nursing intervention? 1.Elevate the buttocks. 2.Apply ice immediately. 3.Document the findings. 4.Notify the registered nurse immediately. - correct answer ✅3.Document the findings. A fresh colostomy stoma will be red and edematous, but this will decrease with time. The colostomy site will then be pink without evidence of abnormal drainage, swelling, or skin breakdown. The nurse would document these findings because this is a normal expectation. Options 1, 2, and 4 are inappropriate interventions. A 1-year-old child is diagnosed with intussusception. The mother of the child asks the nurse to describe the disorder. The nurse should base the response on which description of this disorder? 1.An acute bowel obstruction 2.A condition that causes an acute inflammatory process in the bowel 3.A condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel 4.A condition in which a distal segment of the bowel prolapses into a proximal segment of the bowel - correct answer ✅3.A condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel
questions and answers
HomeHelpCalculator Study Mode Question 35 of 49 ID: 2236 | file: Pediatric PreviousGoNext StopBookmark Rationale Strategy Reference Submit A 1-year-old child is diagnosed with intussusception. The mother of the child asks the nurse to describe the disorder. The nurse should base the response on which description of this disorder? Rationale:Intussusception occurs when a proximal segment of the bowel prolapses into a distal segment of the bowel. It is a common cause of acute bowel obstruction in infants and young children. It is not an inflammatory process. A child is diagnosed with intussusception. The nurse collects data on the child, knowing that which is a characteristic of this disorder? 1.The presence of fecal incontinence 2.Incomplete development of the anus 3.The infrequent and difficult passage of dry stools 4.Invagination of a section of the intestine into the distal bowel - correct answer ✅4.Invagination of a section of the intestine into the distal bowel
questions and answers
1."I can give my child rice." 2."My child loves corn. I will be sure to include corn in the diet." 3."I will be sure to give my child vitamin supplements every day." 4."I am so pleased that I won't have to eliminate oatmeal from my child's diet." - correct answer ✅4."I am so pleased that I won't have to eliminate oatmeal from my child's diet." Dietary management is the mainstay of treatment for the child with celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early period of treatment to correct deficiencies. A nursing student is preparing to conduct a clinical conference, and the topic is hepatitis in children. The nursing instructor advises the student to further research the topic if the student plans to include which information in the discussion? 1.The child's stools will be pale and clay-colored. 2.Cases of hepatitis should be promptly reported to health care officials. 3.Vaccines are available to prevent hepatitis A (HAV) and hepatitis B (HBV). 4.Enteric precautions are necessary for hepatitis B (HBV) but not for hepatitis A (HAV). - correct answer ✅4.Enteric precautions are necessary for hepatitis B (HBV) but not for hepatitis A (HAV). Prevention of the spread of infection is an essential intervention for hepatitis A. This should include enteric precautions for at least 1 week after the onset of
questions and answers
jaundice and strict hand washing. Options 1, 2, and 3 are accurate regarding hepatitis. The nurse is assisting a primary health care provider with an assessment of a child with a diagnosis of suspected appendicitis. In assessing the intensity and progression of the pain, the primary health care provider palpates the child at McBurney's point. What response does the nurse expect the child to have during the examination? 1.Pain in the upper right side 2.Pain when extending the leg 3.Pain when the right thigh is drawn up 4.Pain in the lower right side between the umbilicus and the iliac crest - correct answer ✅4.Pain in the lower right side between the umbilicus and the iliac crest Pain in the lower right side, halfway between the umbilicus and the crest of the ileum at McBurney's point is the best known symptom of appendicitis. Extending the leg causes pain but is not the McBurney's point. The client may rest with the right thigh drawn up to relieve pain. The nurse is reviewing the health record of a child with a diagnosis of celiac disease. Which clinical manifestation should the nurse expect to note documented in the health record? 1.Frothy diarrhea 2.Foul-smelling ribbon stools
