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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 is teaching the mother of an infant with a temporary ileostomy about stoma care. What is the most important instruction to emphasize to the mother to avoid an emergency situation? "Call the doctor immediately if the stoma is not pink/red and moist." "Gather all of your supplies before you begin." "You may need adhesive remover to ease pouch removal." "You must be meticulous in caring for the surrounding skin."
"Call the doctor immediately if the stoma is not pink/red and moist." Explanation: A healthy stoma is pink and moist. If the stoma is dry or pale, the mother must notify the health care provider immediately because it could indicate compromised circulation. Gathering supplies is important but would not be involved in avoiding an emergency situation. All of the other instructions are valid, but emphasizing the color of the healthy stoma is most important to avoid an emergency situation. Adhesive remover may be needed to ease pouch removal, but this action would not necessarily avoid an emergency situation. Meticulous skin care is important, but this action would not necessarily avoid an emergency situation.
The nurse is assessing a toddler and palpates a sausage-shaped mass in the upper mid abdomen. When taking the toddler's history, what question would the nurse ask the parent first? "Has your toddler been having different colored stools?" "Can you describe any pain your toddler is having?" "How is your toddler's appetite?" "Has your toddler been around anyone who has been sick?"
"Has your toddler been having different colored stools?" Explanation: A sausage-shaped mass in the upper mid abdomen is a classic sign of intussusception. Intussusception occurs when the proximal segment of the bowel "telescopes" into a more distal segment of the bowel, thus the sausage-shaped mass. Another classic sign of intussusception is stools that appear like currant jelly. These are stools which are bloody and mixed with mucus. This should be the question the nurse asks first. Next, the nurse should ask about the pain. The pain with intussusception has a sudden onset and is intermittent and crampy. The appetite of the child generally is poor due to abdominal pressure and pain. Intussusception is not a contagious or infectious disease.
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.
A nurse caring for an infant born with a cleft palate notices that the parents rarely interact with their child. The nurse overhears the mother telling her spouse that she "feels like crying" every time she looks at their infant. What would be the best response from the nurse? "I sense you could use more information on caring for a cleft palate. Would you be interested in meeting with other parents who have dealt with this?" "Your infant needs you right now. You should put your negative feelings about the condition aside for your infant's sake." "Many infants are born with this condition. Your infant's palate is not nearly as bad as some cases." "Keep in mind that your infant's condition is not life-threatening and can be corrected eventually."
"I sense you could use more information on caring for a cleft palate. Would you be interested in meeting with other parents who have dealt with this?" Explanation: For many parents, having their infant born with a cleft lip or palate is overwhelming and to some even appalling. The nurse can support the parents by acknowledging their normal feelings of guilt, anger, and sadness. The nurse should support the family's adjustment to an infant's condition by demonstrating an accepting, caring attitude toward the child and family and providing the parents with opportunities and support for normal infant-parent interactions. Many parents need additional support outside the hospital or during surgical repairs. Parent-to-parent support groups are available and parents should be given information about to how to contact a local group. It may be difficult for a parent to bond with an infant who the parent feels is not perfect and those feeling cannot be easily dismissed. It does not matter if the defect is not life-threatening; it is still important to the parents and requires much skill to repair and heal. Stating this is being judgmental.
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." 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 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 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 nurse is caring for an infant recently diagnosed with oral candidiasis (thrush) who has been prescribed nystatin. Which statement by the infant's mother would suggest a need for further education? "I will add the nystatin to her bottle four times per day." "I will use a cotton tipped applicator to apply the medication to her mouth." "I will make sure to clean all of her toys before I give them to her." "I will watch for diaper rash."
"I will add the nystatin to her bottle four times per day." Explanation: Administer nystatin suspension four times per day following feeding, not mixed in the bottle, to allow the medication to remain in contact with the lesions. In the younger infant, apply nystatin to the lesions with a cotton-tipped applicator. Infants and young children often mouth their toys, so it is important to clean them appropriately. Explain to parents of infants with oral candidiasis (thrush) the importance of reporting diaper rash because fungal infections in the diaper area often occur concomitantly with thrush and also need to be treated.
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 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 oat 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 oat 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 mother of a young child who has been treated for a bacterial urinary tract infection tells the nurse her daughter has a white thick covering over her tongue. The mother states that she "has tried everything to get it off my child's tongue." How should the nurse respond? "Have you tried using a toothbrush to get it off?" "That is a common side effect after taking an antibiotic. It will go away after the antibiotic is out of the system." "It is likely an infection was caused by the antibiotic for the urinary tract infection. I am sure a different antibiotic will help it." "It's not unusual for a fungal infection to occur while taking an antibiotic for an infection. I will let your primary care provider know so we can get it treated
"It's not unusual for a fungal infection to occur while taking an antibiotic for an infection. I will let your primary care provider know so we can get it treated." Explanation: Oral candidiasis (thrush) is a fungal infection that can occur on the tongue while on an antibiotic for an unrelated bacterial infection. The antibiotic destroys normal flora, which allows the fungal infection to occur. Thrush requires an antifungal agent, such as nystatin liquid, to destroy the infection. Additional antibiotics will not help since it is a fungal infection.
The mother of a young child who has been treated for a bacterial urinary tract infection tells the nurse her daughter has a white thick covering over her tongue. The mother states that she "has tried everything to get it off my child's tongue." How should the nurse respond? "Have you tried using a toothbrush to get it off?" "That is a common side effect after taking an antibiotic. It will go away after the antibiotic is out of the system." "It is likely an infection was caused by the antibiotic for the urinary tract infection. I am sure a different antibiotic will help it." "It's not unusual for a fungal infection to occur while taking an antibiotic for an infection. I will let your primary care provider know so we can get it treated."
"It's not unusual for a fungal infection to occur while taking an antibiotic for an infection. I will let your primary care provider know so we can get it treated." Explanation: Oral candidiasis (thrush) is a fungal infection that can occur on the tongue while on an antibiotic for an unrelated bacterial infection. The antibiotic destroys normal flora, which allows the fungal infection to occur. Thrush requires an antifungal agent, such as nystatin liquid, to destroy the infection. Additional antibiotics will not help since it is a fungal infection.
The nurse is caring for a child with gastrointestinal concerns. What statement by the parent would indicate a need for the nurse to further assess the child for constipation? "My child has such large bowl movements that it clogs the toilet." "My child only has a bowel movement about four times a week." "My child eats vegetables and fresh fruit, but does not like beans." "My child does not have liquid stool or leak liquid stools that I am aware of."
"My child has such large bowl movements that it clogs the toilet." Explanation: Constipation may manifest by bowel movements that are large enough to clog the toilet, fewer bowel movements than normal, and bowel movements that are hard and pellet-like. Constipation is not likely if the child eats fruits and vegetables, even when beans are not incorporated into the child's diet. Passage of liquid stools can be a sign of constipation.
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." 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 discussing the treatment of congenital aganglionic megacolon with the caregivers of a child diagnosed with this disorder. Which statement is the best explanation of the treatment for this diagnosis? "The treatment for the disorder will be a surgical procedure." "Your child will be treated with oral iron preparations to correct the anemia." "We will give enemas until clear and then teach you how to do these at home." "Your child will receive counseling so the underlying concerns will be addressed."
"The treatment for the disorder will be a surgical procedure." Explanation: Treatment of congenital aganglionic megacolon involves surgery with the ultimate resection of the aganglionic portion of the bowel. Chronic anemia may be present, but iron will not correct the disorder. Enemas may be given to initially achieve bowel elimination, but they will not treat the disorder. Differentiation must be made between this condition and psychogenic megacolon because of coercive toileting or other emotional problems. The child with aganglionic megacolon does not withhold stools or defecate in inappropriate places, and no soiling occurs.
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 child is experiencing an acute exacerbation of Crohn disease for which she is prescribed prednisone. The nurse teaches the parents and child about this medication. Which statement by the parents indicates that the teaching was successful? "We should not stop this medication abruptly." "She might lose some weight initially." "This drug helps to control the abdominal cramping." "We might notice some of the medication in her stool."
"We should not stop this medication abruptly." Explanation: Prednisone is a corticosteroid. Stopping the medication abruptly could lead to adrenal insufficiency. Weight gain would be associated with corticosteroid use. Weight loss is associated with the disease. Corticosteroids help to reduce inflammation and suppress the normal immune response. Typically, anti-inflammatory agents such as mesalamine may appear in the stool. This indicates poor absorption.
The nurse is caring for a 13-year-old girl with suspected autoimmune hepatitis. The girl inquires about the testing required to evaluate the condition. How should the nurse respond? "You will most likely have a blood test to check for certain antibodies." "You will most likely have an ultrasound evaluation." "You will most likely have viral studies." "You will most likely be tested for ammonia levels."
"You will most likely have a blood test to check for certain antibodies." Explanation: Anti-nuclear antibodies are one of the diagnostic tests performed to diagnose autoimmune hepatitis. Ultrasound is performed to assess for liver or spleen abnormalities. Viral studies are performed to screen for viral causes of hepatitis. Ammonia levels may be ordered if hepatic encephalopathy is suspected.
The nurse is providing care to a child who has had an appendectomy for a perforated appendix. The nurse would anticipate intravenous antibiotic therapy for how long? 7 to 14 days 5 to 7 days 3 to 5 days 1 to 3 days
7 to 14 days Explanation: The child with a perforated appendix requires 7 to 14 days of intravenous antibiotic therapy. If the child has a suppurative or gangrenous appendix that was not perforated, 2 to 3 days of antibiotics would be most likely ordered.
A child is diagnosed with intussusception. The nurse anticipates that what action would be attempted first to reduce this condition? Barium enema Surgery Upper endoscopy Endoscopic retrograde cholangiopancreatography
Barium enema Explanation: A barium enema is successful in reducing a large percentage of intussusception cases. Other cases are reduced surgically. Upper endoscopy is used to visualize the upper gastrointestinal tract from the mouth to the upper jejunum. Endoscopic retrograde cholangiopancreatography is used to view the hepatobiliary system.
The nurse is administering an enteral feeding to a child with a gastrostomy tube (G-tube). Which action will the nurse take when administering a prescribed feeding through the client's G-tube? Check for gastric residual before starting feeding. Position the client with the head of the bed at a 20° angle. Use a syringe plunger to administer the feeding. After feeding, flush the tube with a small amount of saline and leave the G-tube open for 2 minutes.
Check for gastric residual before starting feeding. Explanation: The nurse should check for gastric residual before starting feeding by gently aspirating from the tube with a syringe or positioning the tube below the level of the stomach with only the barrel of the syringe attached. The client should be positioned with his or her head elevated 30° to 45° and the formula should be allowed to flow with gravity, not plunged unless the tube is clogged. After feeding, the nurse should flush the tube with a small amount of water, unless contraindicated, and leave the G-tube open for 5 to 10 minutes after feeding to allow for escape of air.
A nurse is caring for a 6-year-old girl recently diagnosed with celiac disease and is discussing dietary restrictions with the girl's mother. Which response indicates a need for further teaching? "My daughter is eating more vegetables." "There is gluten hidden in unexpected foods." "There are many types of flour besides wheat." "My daughter can eat any kind of fruit."
Correct response: "My daughter can eat any kind of fruit." Explanation: While most fruits and fruit juices are allowed, the nurse needs to make sure the mother knows that some fruit pie fillings and dried fruit may contain gluten.
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?"
Correct response: "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.
A child is diagnosed with intussusception. The nurse anticipates that what action would be attempted first to reduce this condition? Barium enema Surgery Upper endoscopy Endoscopic retrograde cholangiopancreatography
Correct response: Barium enema Explanation: A barium enema is successful in reducing a large percentage of intussusception cases. Other cases are reduced surgically. Upper endoscopy is used to visualize the upper gastrointestinal tract from the mouth to the upper jejunum. Endoscopic retrograde cholangiopancreatography is used to view the hepatobiliary system.
x A child presents with intermittent abdominal pain, severe anorexia, and diarrhea. The child's height and weight are significantly behind standards for age. There is skin breakdown in the anal region. The nurse explains that this presentation is consistent with which diagnosis? Crohn disease ulcerative colitis food poisoning Hirschsprung disease
Crohn disease Explanation: Intermittent abdominal pain, anorexia, diarrhea, growth delays, and perianal lesions are characteristic of Crohn disease. In ulcerative colitis, the pain is continuous with bloody diarrhea, but anorexia, weight loss, and growth delay are mild. Food poisoning is an acute condition and may result in weight loss but not growth delays. In Hirschsprung disease the bowel lacks nerve innervation, so it lacks motility and fecal output.
The nurse is caring for a child admitted with gastroesophageal reflux (GER). Which clinical manifestation would likely be seen in this child? Effortless vomiting just after the child has eaten Forceful vomiting followed by the child being eager to eat again Severe constipation with occasional ribbon-like stools Bouts of diarrhea with failure to gain weight
Effortless vomiting just after the child has eaten Explanation: The child with GER usually gains weight and feeds well. It must be determined if there are underlying symptoms or complications that might suggest GERD. In the child with GERD, almost immediately after feeding, the child vomits the contents of the stomach. The vomiting is effortless, not projectile in nature. The child with GERD is irritable and hungry, but may refuse to eat. Aspiration after vomiting may lead to respiratory concerns, such as apnea, wheezing, cough, and pneumonia. Failure to thrive and lack of normal weight gain occurs. Symptoms seen in the older child may include heartburn, nausea, epigastric pain, and difficulty swallowing. Forceful vomiting with the child wanting to eat shortly after vomiting is associated with pyloric stenosis. Severe constipation with ribbon-like stools would be indicative of Hirschsprung disease. Bouts of diarrhea with failure to gain weight is associated with Crohn disease.
A preschooler has celiac disease. The parent is preparing a gluten-free diet. The nurse knows that the parent understands the diet when the parent prepares which breakfast foods? Eggs and orange juice Wheat toast and grape jelly Cheerios (oat cereal) and skim milk Rye toast and peanut butter
Eggs and orange juice Explanation: Celiac disease is an immunological disorder in which gluten causes damage to the small intestines. Gluten is commonly found in grains. Children with celiac disease cannot digest the protein in common grains, such as wheat, rye, and oats. Providing foods with rye, wheat, and oats would cause the child to develop symptoms and worsen the situation.
The mother of a newborn with a cleft lip reports she is having a hard time looking her baby. What is the best action by the nurse? Explain that surgery will make this better in the future. Encourage the mother to provide care for her infant. Encourage the child's mother to hold her infant against her shoulder to provide closeness while not looking at the defect. Tell the mother that while this is difficult it will get easier.
Encourage the mother to provide care for her infant. Explanation: Providing care to the infant is the best means for the mother to begin bonding with her baby. Activities such as feeding, diapering and bathing will be helpful. Encouraging the mother to avoid looking at the cleft lip will not assist her in the process of accepting it. While surgery will be performed it will not take place for a few months. making it vital that she begin bonding with her infant. Telling the parent she will get used to it minimizes her concerns and is not the most therapeutic response by the nurse.
A parent brings the 2-week-old infant to the office because the infant has been experiencing gastroesophageal reflux over the past week. Which intervention(s) should the nurse recommend to the parent at this point? Select all that apply. Feed the infant a formula thickened with rice cereal. Feed the infant while holding the infant in an upright position. Keep the infant upright by holding them and/or elevating the head of the crib after feeding. If breastfeeding, switch to feeding the infant formula. Consult the heath care provider regarding having botulinum toxin injected into the lower esophageal sphincter. Consult a pediatric surgeon regarding having a myotomy procedure performed.
Feed the infant a formula thickened with rice cereal. Feed the infant while holding the infant in an upright position. Keep the infant upright by holding them and/or elevating the head of the crib after feeding. Explanation: The traditional treatment of gastroesophageal reflux in the infant is to feed a formula thickened with rice cereal (1 tbsp of cereal per 1 oz of formula or breast milk) while holding the infant in an upright position and then keeping the infant upright by holding them and/or elevating the head of the crib 30 degrees for 30 to 45 minutes after feeding so gravity can help prevent reflux. There is no need for the parent to switch from breastfeeding to formula-feeding. Injection of botulinum toxin into the lower esophageal sphincter and a myotomy procedure are interventions that would be considered only if the problem does not disappear with feeding solid food and maintaining the infant in a more upright position during and following feeding; these procedures would not be appropriate at this point.
A parent brings the 2-week-old infant to the office because the infant has been experiencing gastroesophageal reflux over the past week. Which intervention(s) should the nurse recommend to the parent at this point? Select all that apply. Feed the infant a formula thickened with rice cereal. Feed the infant while holding the infant in an upright position. Keep the infant upright by holding them and/or elevating the head of the crib after feeding. If breastfeeding, switch to feeding the infant formula. Consult the heath care provider regarding having botulinum toxin injected into the lower esophageal sphincter. Consult a pediatric surgeon regarding having a myotomy procedure performed.
Feed the infant a formula thickened with rice cereal. Feed the infant while holding the infant in an upright position. Keep the infant upright by holding them and/or elevating the head of the crib after feeding. The traditional treatment of gastroesophageal reflux in the infant is to feed a formula thickened with rice cereal (1 tbsp of cereal per 1 oz of formula or breast milk) while holding the infant in an upright position and then keeping the infant upright by holding them and/or elevating the head of the crib 30 degrees for 30 to 45 minutes after feeding so gravity can help prevent reflux. There is no need for the parent to switch from breastfeeding to formula-feeding. Injection of botulinum toxin into the lower esophageal sphincter and a myotomy procedure are interventions that would be considered only if the problem does not disappear with feeding solid food and maintaining the infant in a more upright position during and following feeding; these procedures would not be appropriate at this point.
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.
x 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 child is hospitalized with dehydration as a result of rotavirus. When reviewing the plan of treatment, what can the nurse anticipate will be included? Select all that apply. antidiarrheal agents antibiotic therapy IV fluid administration monitor of intake and output daily weight assessment
IV fluid administration monitor of intake and output daily weight assessment Rotavirus is viral in nature. Antibiotic therapy is not used in the care and treatment of a viral infection. Antidiarrhea medications are not utilized as they are not effective. Intake and output will be observed. Daily weight will aid in the determination of hydration status. IV fluids may be indicated in the rehydration process.
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.
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.
A 9-month-old girl is brought to the emergency room with what appears to be bouts of intense abdominal pain 15 minutes apart in which she draws up her legs and cries, often accompanied by vomiting. In between the bouts, the child recovers and appears to be without symptoms. Blood is found in the stool. What condition should the nurse suspect in this case? Intussusception Volvulus with malrotation Necrotizing enterocolitis Short-bowel/short-gut syndrome
Intussusception Explanation: Intussusception, the invagination of one portion of the intestine into another, usually occurs in the second half of the first year of life. Children with this disorder suddenly draw up their legs and cry as if they are in severe pain; they may vomit. After the peristaltic wave that caused the discomfort passes, they are symptom-free and play happily. In approximately 15 minutes, however, the same phenomenon of intense abdominal pain strikes again. After approximately 12 hours, blood appears in the stool and possibly in vomitus, described as a "currant jelly" appearance. Volvulus with malrotation and necrotizing enterocolitis typically occur in the first 6 months of life and do not match the symptoms described above. Short-bowel/short-gut syndrome typically occurs when a large portion of the intestine has been removed due to a previous disease or trauma.
A 10-year-old male presents with low-grade fever, nausea, and abdominal pain. The nurse examining him suspects appendicitis and checks for rebound tenderness in what quadrant? Upper left Upper right Lower left Lower right
Lower right Explanation: With appendicitis, percussion reveals irritation and pain in the right lower quadrant. Rebound tenderness present with palpation in the right lower quadrant is referred to as the McBurney point, an area of tenderness 1.5 to 2 inches (3.8 to 5 cm) in from the right anterior superior iliac spine along a line extending to the umbilicus.
The nurse is caring for a teenager diagnosed with acute pancreatitis. Which order would the nurse question? NPO nasogastric tube placed to suction serum amylase levels PO pain management
PO pain management Explanation: Maintain NPO status and nasogastric tube suction and patency. Administer intravenous fluids to keep the child hydrated and correct any alterations in fluid and electrolyte balance. Pain management is crucial in children with pancreatitis; due to NPO status, medications are typically prescribed intravenously. Serial monitoring of serum amylase levels will determine when oral feeding may be restarted.
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.
In caring for an infant diagnosed with pyloric stenosis the nurse would anticipate which intervention? Prepare the infant for surgery. Assist in insertion of a nasogastric (NG) tube. 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 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 nasogastric (NG) tube is inserted for gastric decompression in an infant with intussusception.
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.
The nurse is caring for a 6-month-old infant with diarrhea and dehydration. The parent is concerned because the infant has some patches on the tongue. Which feature indicates a geographic tongue? Some patches are light in color and other patches are dark in color. The patches are thick, white plaques on the tongue. There are also plaques on the buccal mucosa. There are also white patches on the erupted teeth.
Some patches are light in color and other patches are dark in color. Explanation: A geographic tongue is a benign, noncontagious condition characterized by a reduction in the filiform papillae. Oral candidiasis (thrush) is characterized by thick, white plaques that form on the tongue. With thrush, plaques also appear on the buccal mucosa and often occur concomitantly in the diaper area. There would not be any patches on the few teeth the infant may have by that age.
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.
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 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. :
The nurse is assessing a 10-day-old infant for dehydration. Which finding indicates severe dehydration? Pale and slightly dry mucosa Blood pressure of 80/42 mm Hg Tenting of skin Soft and flat fontanels (fontanelles)
Tenting of skin Explanation: Tenting of skin is an indicator of severe dehydration. Soft and flat fontanels (fontanelles) indicate mild dehydration. Pale and slightly dry mucosa indicates mild or moderate dehydration. Blood pressure of 80/42 mm Hg is a normal finding for an infant.
An adolescent is diagnosed with hepatitis A. Which problem should be considered when planning care? The adolescent will become fatigued easily. The adolescent will be very irritable and perhaps require sedation. Hypothermia is common. The adolescent's urine will be dark and infectious.
The adolescent will become fatigued easily. Explanation: Hepatitis A is transmitted via the oral-fecal route; it is water borne and often occurs in areas of poor sanitation. The adolescent with hepatitis A will exhibit flu-like symptoms, a headache, anorexia and fatigue. The urine is not infectious and fever may be present as opposed to hypothermia. Irritability is not one of the symptoms of hepatitis A. The client is usually lethargic or listless.
The newborn was diagnosed with esophageal atresia and a nasogastric tube was inserted. Which findings are most consistent with this condition? Select all that apply. The newborn's mouth was very dry. The newborn coughed excessively during attempts to feed. The newborn's skin was very jaundiced. Coarse crackles were auscultated throughout all lung fields. X-ray revealed that the nasogastric tube was coiled in the upper esophagus.
The newborn coughed excessively during attempts to feed. Coarse crackles were auscultated throughout all lung fields. X-ray revealed that the nasogastric tube was coiled in the upper esophagus. Newborns with esophageal atresia cough during attempts to feed, may have fluid in their lungs, and x-rays will show that nasogastric tubes just coil in the upper part of the esophagus because the esophagus does not extend to the stomach. They have increased salivation in their mouths and their skin may be dusky or cyanotic.
The nurse is talking with a woman in her second trimester of pregnancy who has been diagnosed with polyhydramnios. The physician has ordered an ultrasound be performed to check for the presence of esophageal atresia. Which statement by the woman indicates an understanding of the relationship between these conditions? "Babies with esophageal atresia produce an excessive amount of amniotic fluid." "Reductions in amniotic fluid are associated with the development of esophageal atresia." "Babies with esophageal atresia have an inability to swallow amniotic fluid causing the excess buildup." "Enzymes in amniotic fluid can cause the development of esophageal atresia."
The nurse is talking with a woman in her second trimester of pregnancy who has been diagnosed with polyhydramnios. The physician has ordered an ultrasound be performed to check for the presence of esophageal atresia. Which statement by the woman indicates an understanding of the relationship between these conditions? "Babies with esophageal atresia produce an excessive amount of amniotic fluid." "Reductions in amniotic fluid are associated with the development of esophageal atresia." "Babies with esophageal atresia have an inability to swallow amniotic fluid causing the excess buildup." "Enzymes in amniotic fluid can cause the development of esophageal atresia."
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 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.
x 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 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.
The labor and delivery nurse is caring for a mother who has demonstrated polyhydramnios upon delivery. The newborn displays copious, frothy bubbles of mucus in the mouth and nose, as well as drooling. The nurse is concerned that the infant has what disorder? esophageal atresia omphalocele gastroschisis hiatal hernia
esophageal atresia Explanation: Esophageal atresia refers to a congenitally interrupted esophagus where the proximal and distal ends do not communicate; the upper esophageal segment ends in a blind pouch and the lower segment ends a variable distance above the diaphragm. Polyhydramnios is often the first sign of esophageal atresia because the fetus cannot swallow and absorb amniotic fluid in utero, leading to accumulation. Omphalocele and gastroschisis are congenital anomalies of the anterior abdominal wall. Hiatal hernia involves a weakened diaphragm.
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).
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 TAKE ANOTHER QUIZ
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).
The nurse is caring for a 12-year-old child with Crohn disease. What assessment finding will the nurse report to the health care provider when caring for the child? clear lung sounds fever no joint swelling report of a headache
fever Explanation: Crohn disease may affect any area of the digestive tract. It causes acute and chronic inflammation. It may also cause abscesses and fistulas. Inflammation and abscesses can cause fever. An increasing temperature could be the manifestation of the inflammation worsening or the development of an abscess and subsequent infection. The progression of the disease will be reported to the health care provider. A headache may accompany the fever and is a sign of generally not feeling well. It does not indicate progression of the disease, thus does not need to be reported. Clear lung sounds and no swollen joints are good signs, but they are not associated with Crohn disease.
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.
The parent reports that the health care provider said that the infant had a hernia but cannot remember which type. When recalling what the health care provider said, the parent said that a surgeon will repair it soon and there is no problem with the testes. Which hernia type is anticipated? diaphragmatic hernia umbilical hernia inguinal hernia hiatal hernia
inguinal hernia Explanation: An inguinal hernia occurs primarily in males and allows the intestine to slip into the inguinal canal, resulting in swelling. If the intestine becomes trapped and circulation is impaired, surgery is indicated within a short period of time. The diaphragmatic hernia has implications with the respiratory system. An umbilical hernia typically spontaneously closes by age 3. A hiatal hernia produces digestive issues.
A parent brings the 10-year-old child in to the clinic. The nurse notes: icteric sclera and skin, headache, anorexia, vomiting, and temperature 101.8°F (38.8°C). The parent states the child has had the symptoms since returning to the US from India a few days ago. The nurse will anticipate preparing the child for which test? liver function tests abdominal ultrasound fecal ova and parasite test magnetic resonance imaging (MRI)
liver function tests Explanation: The nurse would anticipate preparing the child for liver function tests due to the suspicion of the child having hepatitis A. It is a communicable disease of the liver caused by the hepatitis A virus. It is transmitted person-to-person through the fecal-oral route or by consumption of contaminated food or water. The symptoms of hepatitis A include pain in the abdomen, joints, or muscles; jaundice; nausea; vomiting; diarrhea; fatigue; fever and anorexia. Traveling to an at-risk country also is an indicator for the nurse. Alanine transaminase (ALT) and aspartate transaminase (AST) are commonly used to diagnosis hepatitis A. An ultrasound, MRI, nor fecal test are not indicated for this client based on the presenting symptoms. Additional testing may be indicated if the liver testing is negative.
The nurse is reviewing the medical record of a child with a cleft lip and palate. When reviewing the child's history, what would the nurse identify as a risk factor for this condition? mother age 42 with pregnancy maternal use of acetaminophen in third trimester preterm birth history of hypoxia at birth
mother age 42 with pregnancy Explanation: Advanced maternal age is a risk factor for cleft lip and palate. Drugs such as anticonvulsants, steroids, and other medications during early pregnancy are considered risk factors. Acetaminophen is not associated with an increased risk for cleft lip and palate. Preterm birth is not a risk factor for the development of cleft lip and palate. Hypoxia or anoxia is a risk factor for the development of necrotizing enterocolitis.
A parent brings a 10-year-old child to the emergency room with reports of abdominal pain. The nurse performing a physical assessment notes the following symptoms: upper right quadrant pain that radiates to the back; fever; nausea; and abdominal distention. Which disease would the nurse suspect? pancreatitis appendicitis Crohn disease ulcerative colitis
pancreatitis Explanation: The child admitted with the suspicion of pancreatitis typically reports acute onset of persistent abdominal pain. It can be mid-epigastric or periumbilical with radiation to the back or the chest. Nausea and vomiting, fever, tachycardia, hypotension, and jaundice may be present. Abdominal signs such as abdominal distention, decreased bowel sounds, rebound tenderness, and guarding also may be noted. Appendicitis pain and tenderness would be localized to the right lower quadrant. Crohn disease is a chronic bowel disorder causing frequent, recurring diarrhea. Ulcerative colitis is a chronic bowel disease affecting the large intestine and the rectum.
The nurse is obtaining the history of an infant with a suspected intestinal obstruction. Which response regarding newborn stool patterns would indicate a need for further evaluation for Hirschsprung disease? passed a meconium stool in the first 24 to 48 hours of life has had diarrhea for 3 days constipated and passing gas for 2 days passed a meconium plug
passed a meconium plug Explanation: If the parent reports that the child passed a meconium plug, the infant should be evaluated for Hirschsprung disease. Constipation, not diarrhea, is associated with this condition; however, constipation alone would not necessarily warrant further evaluation for Hirschsprung disease. Passing a meconium stool in the first 24 to 48 hours of life is normal.
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 group of nursing students are reviewing information about celiac disease. The students demonstrate understanding of this disorder when they identify which classic symptoms? Select all that apply. steatorrhea constipation diarrhea failure to thrive sunken abdomen polycythemia
steatorrhea constipation diarrhea failure to thrive Classic symptoms of celiac disease include steatorrhea, constipation, diarrhea, failure to thrive, weight loss, abdominal distention or bloating (not a sunken abdomen), and anemia (not polycythemia).
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.
A child with liver cirrhosis is admitted to the acute care facility in preparation for a liver transplant. What finding(s) would the nurse document after completing this child's assessment? Select all that apply. yellow skin and sclera liver palpable palms of hands reddened confused mental status fatty, foul-smelling stool
yellow skin and sclera liver palpable palms of hands reddened confused mental status A child with cirrhosis would have symptoms of nausea and vomiting, jaundice, palmar erythema, ascites, weight loss, and an enlarged liver. The child's mental status could be clear or it could be confused if hepatic encephalopathy is present. The nurse would document the findings as to the amount of jaundice present, the weight of the child, the measurement of the abdomen to determine ascites, the amount of redness in the palms, and whether the liver is palpable or not. Fatty, foul-smelling stools are not seen with cirrhosis. These would be more likely in conditions like cystic fibrosis or celiac disease.
