Chapter 42: Nursing Care of the Child With an Alteration in Bowel Elimination/Gastrointestinal Disorder
A nurse is teaching the parent of a school-age who has celiac disease. Which of the following foods selected by the parent indicates an understanding of teaching? A. Corn tortilla with black beans B. Pizza c. canned soup D. Hot dogs
A
A nurse is caring for an infant who is experiencing dehydration. Which of the following assessments is the nurse priority? a. Measure the client's weight daily b. Check for tears c. Palpate the fontanel d. Assess skin turgor
A Measure the client's weight daily is priority, indicate degree threats to the clients. (Fluid accounts greater portion of body weight)
A nurse is caring for a client who has ulcerative colitis. The provider prescribes bed rest with bathroom privileges. When the client asks the nurse why he has to stay in bed, which following response should nurse provide? A. You need to conserve energy at this time B. Lying quietly in bed helps slow down the activity in your intestine C stay in bed promotes the rest and comfort D. Prevent injury and minimize fall risk
B
A nurse is developing a plan of care for a client after a recent stroke who has a hx of GERD. For which of the following disorders should the nurse monitor this client? A. Duodenal ulcer disease B. Aspiration pneumonia C. Viral pneumonia D. Esophageal varies
B
a nurse is providing dietary teaching to a client who has ulcerative colitis. Which of following food selections by the client indicates an understanding of teaching? A. Raw vegetable salad with low fat B. Roast chicken and white rice C. Fresh fruit and white rice D. Peanut butter on whole wheat bread
B
A nurse in the emergency department is reviewing laboratory results for several children who have manifestations of influenza. Which of the following children should the nurse report to the provider? A. A school age child with a urine specific gravity of 1.035 B. A toddler with BUN of 25 and a creatinine of 0.5 C. An infant with WBC 24.000 D. an adolescent with a positive beta human chronic gonadotropin test
C -An infection can cause sepsis
The caregiver of a child diagnosed with celiac disease tells the nurse that the child has large amounts of bulky stools and what looks like fat in the stools. The clinical manifestation this caregiver is describing is: steatorrhea. severe diarrhea. currant jelly stools. projectile stools.
steatorrhea. Explanation: Celiac disease is an immunologic response to gluten, which causes damage to the small intestine. Steatorrhea (fatty stools) is a classic symptom of celiac disease. Symptoms also include abdominal distention or bloating, constipation, and nutritional deficiencies. Currant jelly stools are a sign of intussusception. Projectile vomiting is a sign of pyloric stenosis. Severe diarrhea could be caused by a bacteria or virus. Projectile stools represent severe diarrhea.
The nurse is caring for a child with a diagnosis of pyloric stenosis during the preoperative phase of the child's treatment. What is the highest priority at this time? Preparing family for home care Promoting comfort Maintaining skin integrity Improving hydration
Improving hydration Explanation: Preoperatively, the highest priority for the child with pyloric stenosis is to improve nutrition and hydration. Maintaining mouth and skin integrity, and relieving family anxiety are important, but these are not the priority. The child will not likely have intense pain. Preparing the family for home care would be a postoperative goal.
A nurse is assessing an adolescent who has appendicitis. Which of the following manifestation should the nurse expect? A. Upper right quadrant adbominal pain B. Rigid abdomen C. Hyperactive bowel sounds D. Bradycardia
B
A nurse is assessing an infant who has acute gastroenteritis. Which of the following finding should the nurse identify as priority? A. Decreased skin turgor B. Capillary refill 5s C. HR 150/min D. Dry mucous membranes
B
a nurse is reviewing the lab results of a child who has experienced diarrhea for the past 24 hr. Which of the following values for urine specific gravity should the nurse expect? A. 1.010 B. 1.035 C. 1.020 D. 1.005
B
A nurse is caring for a client who has celiac disease. Which of the following foods should the nurse remove from the client's meal tray? A. Wheat toast B. Tapioca pudding C. Hard-boiled egg D/ Mashed potatoes
A
A nurse is discussing the cause of chronic diarrhea with a client. Which of the following condition is caused by malabsorption? A. Celiac disease B. Ulcerative colitis C. Hischsprung's disease D. crohn's disease
A
A nurse is discussing the causes of chronic diarrhea with a client. Which of the following condition is caused by malabsorption? A. Celiac disease B. Ulcerative colitis C. Hischsprung's disease D. Crohn's disease
A
A nurse is planning care for toddler who has acute Gastroenteritis and was recently admitted. Which of the following should the nurse plan to provide for the child? A. Oral rehydration solution B. Bananas or applesauce C. Chicken or beef broth D. Hypertonic iv solution
A.
A nurse is caring for a child who has a possible intussusception. The parents of the child ask the nurse how the diagnosis is made. Which of the following responses should the nurse make? A. An abdominal ultrasound will confirm the pocket in the intestine B. Genotyping will be done to identify this condition C. A biopsy will be done on a small amount of tissue from the colon D. An upper GI series identify the area involved
An abdominal ultrasound will confirm the pocket in the intestine
a nurse is caring for an infant who has gastroenteristis and is dehydrated. Which of the following characteristics place the infants at a higher risk of electrolyte imbalances compared to an adult client? A. Less ECF B. Reduced body surface area C. Longer intestinal tract D. Decreased rate of metabolism
C
A nurse is caring for an infant who is 6 months old and has moderate dehydration. Which of the following findings should the nurse expect? A absent tears B. Weight loss > 10% C. Lethargy D. Dry mucous membranes
D
A parent brings a 2-year-old child to the health clinic with reports of diarrhea, vomiting, and abdominal pain. The father tells the nurse that he is a single parent and his child is enrolled in a local day care center. Based on this information, what gastrointestinal condition might the nurse suspect? Appendicitis Pancreatitis Gastroenteritis Hirschsprung disease
Gastroenteritis Explanation: Outbreaks of gastroenteritis routinely occur in day care centers, schools, institutions for the handicapped, and other places where overcrowding is prevalent and hygiene is inadequate. Typical signs and symptoms include diarrhea, nausea, vomiting, and abdominal pain.
A neonatal nurse teaches students how to recognize gastrointestinal disorders in infants. The nurse tells the students that failure of the newborn to pass meconium in the first 24 hours after birth may indicate what disease? Gastroenteritis Ulcerative colitis (UC) Hirschsprung disease Short bowel syndrome (SBS)
Hirschsprung disease Explanation: The nurse should suspect Hirschsprung disease when the newborn does not pass meconium in the first 24 hours after birth, and has bilious vomiting or abdominal distention and feeding intolerance with bilious aspirates and vomiting. Typical signs and symptoms of gastroenteritis include diarrhea, nausea, vomiting, and abdominal pain. The characteristic GI manifestation of UC is bloody diarrhea accompanied by crampy, typically left-sided lower abdominal pain. Clinical manifestations of untreated SBS include profuse watery diarrhea, malabsorption, and failure to thrive.
The emergency department nurse is assessing a child who has presented with a 2-day history of nausea and vomiting with pain that is isolated to the right upper quadrant of the abdomen. Which action is most appropriate? Prepare the child for admission to the hospital. Assess the child's usual urinary voiding pattern. Encourage fluid intake. Administer antacids as ordered.
Prepare the child for admission to the hospital. Explanation: The child's presentation is consistent with cholecystitis, which necessitates surgery in most cases. The child should be kept NPO and antacids are of no benefit. Genitourinary involvement is atypical.
A nurse is reviewing the medical record of a 2 month old infant who has rotavirus. The nurse notes a hemoglobin level of 12 g/dL and a hematocrit of 51%. Which of the following statements by the nurse indicates an understanding of the laboratory values? The infant might be dehydrated The infant might be anemic The infant might have received too much fluid The infant might have leukemia
The infant might be dehydrated
What occurs in the gastrointestinal system of the child with Hirschsprung disease? There is a partial or complete mechanical obstruction in the intestine. There is a severe narrowing of the lumen of the pylorus. There is an invagination or telescoping of one portion of the bowel into a distal portion. There is a relaxed sphincter in the lower portion of the esophagus.
There is a partial or complete mechanical obstruction in the intestine. Explanation: Congenital aganglionic megacolon, also called Hirschsprung disease, is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. A narrowing of the lumen of the pylorus is associated with pyloric stenosis in young infants. The telescoping of the bowel is intussusception. The relaxed sphincter in the lower portion of the esophagus is related to gastrointestinal reflux disorder.
A school nurse is providing dietary teaching for an adolescent who has type 1 DM. Which of the following responses by the adolescent indicates an understanding of the teaching ? (SATA) A. I should eat extra food on busy days when I am more active B. I should wait for 2 hr after eating b4 going swimming with my friends C. increase intake of sugar free fluids D. Eat a snack 30 min before my baseball games start E. 16 oz sports drink if feel weak
acd
The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac syndrome. Which foods would be permitted in the diet of the child with celiac syndrome? Select all that apply. applesauce bananas skim milk rye bread wheat bread
applesauce bananas skim milk Explanation: The child is usually started on a gluten-free, low-fat diet. Skim milk and bananas are usually well tolerated. Lean meats, puréed vegetables, and fruits are gradually added to the diet. Wheat, rye, and oats (unless specifically gluten free) are not included in the diet.
A nurse taking a health history of a newborn notes that there is a maternal history of polyhydramnios. What GI condition might this history precipitate? esophageal atresia (EA) cleft palate pyloric stenosis hernia
esophageal atresia (EA) Explanation: A maternal history of polyhydramnios is usually present in one-third of cases of EA and in some cases of tracheoesophageal fistula (TEF).
An 18-month-old infant is brought to the emergency department with flu-like symptoms. The infant is diagnosed with pneumonia secondary to aspiration of stomach contents. The nurse explains to the parents that pneumonia is a condition that often occurs secondary to: gastroesophageal reflux disease. cystic fibrosis. Hirschsprung disease. inflammatory bowel disease.
gastroesophageal reflux disease. Explanation: Gastroesophageal reflux (GER) is the passage of gastric contents into the esophagus. These refluxed contents may be aspirated into the lungs. The child with gastroesophageal reflux disease may present with the physical findings of pneumonia or GER-induced asthma. GER may cause apnea or an apparent life-threatening event in the younger infant. Pneumonia can occur in children with cystic fibrosis, but the child would need to have the cystic fibrosis diagnosis first. Hirschsprung and inflammatory bowel diseases are diseases of the gastrointestinal tract that do not present with respiratory symptoms.
The nurse is conducting a physical examination of an infant with suspected pyloric stenosis. Which finding indicates pyloric stenosis? sausage-shaped mass in the upper mid abdomen perianal fissures and skin tags abdominal pain and irritability hard, moveable "olive-like mass" in the upper right quadrant
hard, moveable "olive-like mass" in the upper right quadrant Explanation: A hard, moveable "olive-like mass" in the right upper quadrant is the hypertrophied pylorus. A sausage-shaped mass in the upper mid abdomen is the hallmark of intussusception. Perianal fissures and skin tags are typical with Crohn disease. Abdominal pain and irritability is common with pyloric stenosis but are seen with many other conditions.
A 3-month-old is admitted with severe diarrhea. Yesterday, the infant weighed 11 pounds (5 kg). Today, this infant weighs 9 pounds, 8 ounces (4.3 kg). Based on this information the nurse documents that the infant has: severe dehydration. failure to thrive. malabsorption syndrome. risk for fluid volume deficit.
severe dehydration. Explanation: A loss of more than 10% of body weight in a day is a sign of severe dehydration. Failure to thrive and malabsorption syndrome are long-term conditions, not objectively defined by a 24-hour weight change. This child is no longer at risk for a fluid volume deficit but is showing signs of dehydration.
A nurse is caring for a 6 month old who has intussusception. Which of the following actions should the nurse take? A. Prepare to administer high dose steroids B. give the child magnesium hydroxide PO C. prepare the child for a barium enema D. Inform the parents that the child will need a colostomy
C
The nurse is caring for a pediatric client with idiopathic celiac disease. Which meal will the nurse select for this client? Ham and cheese sandwich, orange slices, chips, and whole milk Whole wheat pasta, meatballs, carrot sticks, apple, and water Baked salmon, potato slices, vanilla ice cream, and apple juice Meatloaf, green beans, peanut butter cookie, and fat-free milk
Baked salmon, potato slices, vanilla ice cream, and apple juice Explanation: Celiac disease is an autoimmune condition where contact with gluten causes a reaction from the body's immune system. Clients with celiac disease should be educated to eat a gluten-free diet to decrease symptoms and limit small intestine irritation. Gluten is a protein found in wheat, barley, and rye. Most commercially used flour contains wheat and should be avoided. The nurse would select foods such as meats/fish (salmon), fruits, vegetables (potatoes), and rice. Single flavor ice creams, such as chocolate, vanilla, and strawberry are gluten free, while cookies contain flour and should be avoided. Fruit juices, water, and milk are all gluten free. Meatloaf may contain oats; however, studies suggest oats are fine to consume, as long as the oats did not come into contact with wheat during processing. Reading the label would indicate if wheat was contacted. Sandwich bread and pastas contain gluten unless special gluten-free products are purchased or it is homemade. The nurse would not assume those items were gluten-free.
In caring for an infant diagnosed with pyloric stenosis the nurse would anticipate which intervention? Prepare the infant for surgery. Medicate the infant with analgesics. Change the infant's diet to one that is lactose-free. Assist in doing a barium enema procedure on the infant.
Prepare the infant for surgery. Explanation: In pyloric stenosis, the thickened muscle of the pylorus causes gastric outlet obstruction. The treatment is a surgical correction called a pyloromyotomy. The condition is not painful, so no analgesics would be needed until after surgical repair. The condition is not related to lactose in the diet, so changing to lactose-free formula would not correct the condition. A barium enema would be used to diagnose intussusception.
A 6-week-old infant is diagnosed with pyloric stenosis. When taking a health history from the parent, which symptom would the nurse expect to hear described? Refusal to eat Vomiting about 2 hours after feeding Chronic diarrhea Vomiting immediately after feeding
Vomiting immediately after feeding Explanation: With pyloric stenosis the circular muscle pylorus is hypertrophied. This thickness causes gastric outlet obstruction. The condition is seen in younger infants starting at 3 to 6 weeks of age. The infant has projectile nonbilious vomiting. It occurs directly after eating and is not related to the feeding position. The infant is hungry shortly after eating. There is weight loss and/or dehydration. The treatment is a pyloromyotomy to reduce the increased size and increase the opening. Diarrhea is not associated with the disorder.
The nurse is caring for a 2-year-old child with a gastrointestinal infection resulting in 4 to 5 liquid stools per day over the past 3 days. Based on this information, which important concern(s) will the nurse address in the child's care? Select all that apply. fluid deficiency risk: dehydration diarrhea and loss of electrolytes the risk for skin maceration in the perineum undernourishment risk: malnutrition availability of parents to care for the child
fluid deficiency risk: dehydration diarrhea and loss of electrolytes the risk for skin maceration in the perineum Explanation: Four to five loose stools per day are considered diarrhea. The child is at risk for fluid and electrolyte deficiency given the length of time and number of stools per day. The risk for skin maceration can occur in the perianal area because of the prolonged skin exposure to liquid stools. The child does not have malnutrition. Malnutrition is defined as a condition that results from a nutrient deficiency or overconsumption. Parental presence to care for the child can be addressed after the immediate needs of the child are addressed.
A child with inflammatory bowel disease is started on an anti-inflammatory medication. Which item(s) would the nurse teach the child and parents about being on this type of medication? Select all that apply. Use sunscreen and protective clothing while outside. Increase folic acid intake. Drink adequate fluids to avoid crystallization of sulfa in urine. Administer the medication just after meals to avoid gastrointestinal irritation. Take the medication between meals to increase absorption.
Use sunscreen and protective clothing while outside. Increase folic acid intake. Drink adequate fluids to avoid crystallization of sulfa in urine. Administer the medication just after meals to avoid gastrointestinal irritation. Explanation: Anti-inflammatory medications increase sensitivity to sunlight and may crystalize in the urine. These medications are irritating to the gastric lining and are taken with food to avoid irritation. These drugs decrease folic acid absorption; therefore, parents should anticipate a concurrent prescription for folic acid.
The nurse is teaching the mother of a 5-year-old boy with a history of impaction how to administer enemas at home. Which response from the mother indicates a need for further teaching? "I should position him on his abdomen with knees bent." "He will require 250 to 500 mL of enema solution." "I should wash my hands and then wear gloves." "He should retain the solution for 5 to 10 minutes."
"I should position him on his abdomen with knees bent." Explanation: A 5-year-old child should lie on his left side with his right leg flexed toward the chest. An infant or toddler is positioned on his abdomen. Using 250 to 500 mL of solution, washing hands and wearing gloves, and retaining the solution for 5 to 10 minutes are appropriate responses.
The nurse is preparing a client for surgery and the client asks, "What does it mean when they say they are going to reduce my abdominal hernia?" Which response by the nurse is most appropriate? "This means the hernia contents will be manipulated back into your peritoneal cavity during surgery." "If you do not understand this, I need to cancel your surgery and have the health care provider come back." "All this means is that the herniated intestines are twisted and edematous, which is why you need surgery." "The health care provider will remove about half of the herniated contents during the procedure."
"This means the hernia contents will be manipulated back into your peritoneal cavity during surgery." Explanation: A hernia in the abdominal region is considered reducible when its contents are easily manipulated back through the inguinal ring into the peritoneal cavity. The nurse would reinforce this education, already provided by the primary health care provider when the surgery was explained, to the client. It is not necessary to cancel surgery when the nurse can provide education to the client. Reducing does not mean the intestines are twisted and edematous. Nor does it mean half of the contents will be removed.
A 4-month-old has had a fever, vomiting, and loose watery stools every few hours for 2 days. The mother calls the physician's office and asks the nurse what she should do. Which response by the nurse is most appropriate? "Do not give the child anything to drink for 4 hours. If the fever goes down and the loose stools stop, you can resume breastfeeding." "Continue breastfeeding as you have been doing. The fluid from the breast milk is important to maintain fluid balance." "Give a clear pediatric electrolyte replacement for the next few hours, then call back to report on how your child is doing." "Bring the child to the office today so we can evaluate her fluid balance and determine the best treatment."
"Bring the child to the office today so we can evaluate her fluid balance and determine the best treatment." Explanation: An infant's body comprises a high percentage of fluid that can be lost very quickly when vomiting, fever, and diarrhea are all present. This infant needs to be seen by the physician based on her age and symptoms; hospitalization may be necessary for intravenous rehydration depending upon her status when assessed.
The nurse has performed client education for a 15-year-old boy with Crohn disease and his parents regarding the cobblestone lesions in his small intestine. Which comment by the family indicates learning has occurred? "I have to be careful because I am prone to not absorbing nutrients." "I have a lot of diarrhea every day because of how my small intestine is damaged." "I may end up with a colectomy because the disease is continuous from the beginning to the end of my intestines." "It's unusual for someone my age to get Crohn disease."
"I have to be careful because I am prone to not absorbing nutrients." Explanation: Crohn disease typically affects the small intestine more than the large intestine and its onset is between the ages of 10 to 20 years. The cobblestone lesions in the small intestine prevent absorption of nutrients that normally occurs. The diarrhea is not directly related to the cobblestone lesions, and ulcerative colitis is characterized by the disease affecting the intestine(s) in a continuous pattern.
The nurse is providing discharge teaching regarding oral fluid rehydration to a mother who brought her child to the clinic because of vomiting over the past 2 days. The child is mildly dehydrated. Which comments by the mother indicated learning occurred? "I should not give my child any fluids for 1 to 2 hours after an episode of vomiting." "My child can drink milk if he feels like it to help in rehydration." "Oral rehydration solutions (ORS) are good sources of fluids for rehydration." "I should be sure my child receives 50 to 100 ml/kg of oral rehydration solution (ORS) over 4 hours." "Solutions like Pedialyte are not necessary for mild dehydration."
"I should not give my child any fluids for 1 to 2 hours after an episode of vomiting." "Oral rehydration solutions (ORS) are good sources of fluids for rehydration." "I should be sure my child receives 50 to 100 ml/kg of oral rehydration solution (ORS) over 4 hours." Explanation: In the child with mild to moderate dehydration resulting from vomiting, withhold oral feeding for 1 to 2 hours after emesis, after which time oral rehydration can begin. Tap water, milk, undiluted fruit juice, soup, and broth are not appropriate for oral rehydration. Oral rehydration solutions include Pedialyte, Infalyte, and Ricelyte. The recommendation for children with mild to moderate dehydration is 50 to 100 ml/kg of ORS over 4 hours.
The mother of an infant tells the nurse during a routine visit to the clinic that she often notices a bulging mass in the lower abdominal and groin area when her baby cries. She asks the nurse if this is normal. How should the nurse respond? "The muscle wall of infants are not yet strong so it isn't unusual to see this happening when the baby is crying or straining." "I didn't notice any masses while I was assessing your infant. It may just appear they have a mass due to pressure in the abdomen when crying." "I will be sure to note this in your child's chart so it is something we will continue to monitor in future visits." "I understand your concern. I will be sure to document this in your child's medical record and report this information to your child's physician immediately."
"I understand your concern. I will be sure to document this in your child's medical record and report this information to your child's physician immediately." Explanation: The mother is describing common symptoms of an inguinal hernia. It may be possible to visualize the mass, but often the mass is seen only during crying or straining, making it difficult to actually identify in the clinic setting. It is important to notify the physician so treatment can be initiated.
The student nurse is caring for a child with the nursing diagnosis "Risk for fluid volume deficit related to inadequate oral intake." Which statement by the student would indicate a need for further education by the nursing instructor? "I will monitor her IV line to help maintain her fluid volume." "I will teach her mother to give her small drinks frequently." "I will make sure there is plenty of orange juice available. It's her favorite juice." "I will weigh her every morning at the same time."
"I will make sure there is plenty of orange juice available. It's her favorite juice." Explanation: Proper interventions for children at risk for fluid volume deficit include maintaining IV line and administer IV fluid as ordered to maintain fluid volume. Offer small amounts of oral rehydration solution frequently to maintain fluid volume. Small amounts are usually well tolerated by children with diarrhea and vomiting. Avoid high-carbohydrate fluids such as Kool-Aid and fruit juice, as they are low in electrolytes, and increased simple carbohydrate consumption can decrease stool transit time. Daily weights are one of the best indicators of fluid volume status in children.
The nurse is caring for a 4-year-old with oral vesicles and ulcers from herpangina. The child is refusing fluids due to the pain and the mother is concerned about his hydration status. Which of the suggestions would be most appropriate? "Offer 'magic mouthwash' followed by a popsicle." "Encourage him to have some soda." "Offer him some orange juice." "Try some Anbesol or Kank-A."
"Offer 'magic mouthwash' followed by a popsicle." Explanation: Children are more likely to cooperate with interventions if play is involved. "Magic" analgesic mouthwash followed by a popsicle is most likely to alleviate some pain and then provide hydration. Soda should be avoided because it can cause stinging and burning. Orange juice should be avoided because it can cause stinging and burning. Anbesol might be helpful but it will likely be difficult to apply. Additionally, oral analgesics are often necessary.
The student nurse is preparing a presentation on celiac disease. What information should be included? Select all apply. "Symptoms of celiac disease include diarrhea, steatorrhea, anemia, and dental disorders." "Most children with celiac disease are diagnosed within the first year of life." "The only treatment for celiac disease is a strict gluten-free diet." "Gluten is found in most wheat products, rye, barley and possibly oats." "The entire family will need to eat a gluten-free diet."
"Symptoms of celiac disease include diarrhea, steatorrhea, anemia, and dental disorders." "The only treatment for celiac disease is a strict gluten-free diet." "Gluten is found in most wheat products, rye, barley and possibly oats." Explanation: Celiac disease is an immunologic disorder in which gluten causes damage to the small intestine. The only treatment currently is consuming a gluten-free diet. While the child needs to have a gluten-free diet, the rest of the family does not. Most children present by the age of 2 for evaluation. Symptoms of celiac disease include diarrhea, constipation, steatorrhea, weight loss, poor muscle tone, anemia and dental disorders. Gluten is found in most grains, like wheat, rye, barley and possibly oats.
The nurse is collecting data on a 2-year-old child admitted with a diagnosis of gastroenteritis. When interviewing the caregivers, which question is most important for the nurse to ask? "How many times a day does your child urinate?" "How long has your child been toilet trained?" "Tell me about the types of stools your child has been having." "What foods has your child eaten during the last few days?"
"Tell me about the types of stools your child has been having." Explanation: For the child with gastroenteritis, the interview with the family caregiver must include specific information about the history of bowel patterns and the onset of diarrheal stools, with details on the number and type of stools per day. Recent eating patterns, determining if the child is toilet trained, and how many times a day the child urinates are important questions, but the highest priority is gathering data regarding the stools and stool pattern.
The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements. Which statement is most accurate related to the diagnosis of gastroesophageal reflux? A partial or complete intestinal obstruction occurs. A thickened, elongated muscle causes an obstruction at the end of the stomach. There are recurrent paroxysmal bouts of abdominal pain. In this disorder the sphincter that leads into the stomach is relaxed.
In this disorder the sphincter that leads into the stomach is relaxed. Explanation: Gastroesophageal reflux (GER) occurs when the sphincter in the lower portion of the esophagus, which leads into the stomach, is relaxed and allows gastric contents to be regurgitated back into the esophagus. Congenital aganglionic megacolon is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. Colic consists of recurrent paroxysmal bouts of abdominal pain. Pyloric stenosis is characterized by hypertrophy of the circular muscle fibers of the pylorus, which leads to an obstruction at the distal end of the stomach.
The parent of a 3-week-old infant brings the infant in for an evaluation. During the visit, the parent tells the nurse that the infant is spitting up after feedings. Which response by the nurse would be most appropriate? "Thicken the formula by adding rice cereal." "Infants this age commonly spit up." "Your child might have an allergy." "Do not worry; you are just feeding your infant too much."
Infants this age commonly spit up." Explanation: In infants younger than 1 month of age, the lower esophageal sphincter is not fully developed. Therefore, infants younger than 1 month of age frequently regurgitate after feedings. Many children younger than 1 year of age continue to regurgitate for several months, but this usually disappears with age. Adding rice cereal to the infant formula should only be done when medically indicated and under the recommendation of a health care provider. The parent's report is not a cause for concern, so the health care provider does not need to be notified. Additional information would be needed to determine if the infant had an allergy. Although the infant's stomach capacity is small, telling the parent not to worry does not address the parent's concern, and telling the parent that he or she is feeding the child too much implies that he or she is doing something wrong.
The nurse is caring for a child admitted with pyloric stenosis. Which clinical manifestation would likely have been noted in the child with this diagnosis? Explosive diarrhea Projectile vomiting Severe abdominal pain Frequent urination
Projectile vomiting Explanation: During the first weeks of life, the infant with pyloric stenosis often eats well and gains weight and then starts vomiting occasionally after meals. Within a few days the vomiting increases in frequency and force, becoming projectile. The child may have constipation, and peristaltic waves may be seen in the abdomen, but the child does not appear in severe pain. Urine output is decreased and urination is infrequent.
An adolescent has hepatitis B. What would be the most important nursing action? Conscientious collection of stool for ova and parasites Strict calculation of caloric and vitamin B intake Strict enforcement of standard precautions Close observation to detect cerebral hallucinations
Strict enforcement of standard precautions Explanation: Hepatitis B is spread through IV drug use, sex, contaminated blood and perinatally. The treatment is rest, hydration, and nutrition. Hospitalization is required if there is vomiting, dehydration, elevated bleeding times and mental status changes. The adolescent should be taught about good hygiene, safe sex practices, careful handwashing and blood/bodily fluid contact precautions. Using standard precautions of gloves and good handwashing will help prevent spread of the disease. Ova and parasites are not present with hepatitis B. A good diet with adequate protein and vitamins will help the body heal, so these should not be restricted. The nurse observes for mental status changes. These can occur as a complication, but preventing spread of the disease is the nursing priority.
The nurse is caring for a 6-month-old infant who was admitted to the emergency department 24 hours ago with signs of severe diarrhea. The infant's rectal temperature is 104°F (40°C), with weak and rapid pulse and respirations. The skin is pale and cool. The child is on IV rehydration therapy, but the diarrhea is persisting. The infant has not voided since being admitted. Which is the priority nursing intervention? Take a stool culture Administer antibiotic therapy Administer IV potassium Feed the child a cracker
Take a stool culture Explanation: Treatment of severe diarrhea focuses on regulating electrolyte and fluid balance by initiating a temporary rest for the gastrointestinal tract, oral or IV rehydration therapy, and discovering the organism responsible for the diarrhea. All children with severe diarrhea or diarrhea that persists longer than 24 hours should have a stool culture taken to determine if bacteria are causing the diarrhea; if so, a definite antibiotic therapy can be prescribed. Because a side effect of many antibiotics is diarrhea, antibiotics should not routinely be used to treat diarrhea without an identifiable bacterial cause. Before the initial IV fluid is changed to a potassium solution, be certain the infant or child has voided—proof that the kidneys are functioning; in this case, the child is not voiding yet. The child should not be fed a cracker, as the gastrointestinal tract should be rested until the diarrhea stops.
A nurse is assessing a 6 month old infant who was recently admitted with acute vomiting and diarrhea. Which of the followings indicate the infant has moderate dehydration? A. Bulging anterior fontanel B. Bradycardia C. Tachypnea D. Polyuria
c