Nursing Care of the Child With an Alteration in Bowel Elimination/Gastrointestinal Disorder
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? a) "You may need adhesive remover to ease pouch removal." b) "You must be meticulous in caring for the surrounding skin." c) "Gather all of your supplies before you begin." d) "Call the doctor immediately if the stoma is not pink/red and moist."
"Call the doctor immediately if the stoma is not pink/red and moist."
The nurse is preparing an 18-month-old for discharge after treatment for dehydration following diarrhea. What instruction would the nurse most likely include in the discharge teaching? a) "Give her plenty of fruit juice or soda." b) "Encourage bananas, applesauce, and crackers." c) "Make sure she gets lots of clear liquids." d) "Offer her flavored gelatin if she is hungry."
"Encourage bananas, applesauce, and crackers."
The nurse is caring for a 2-year-old boy with an umbilical hernia and is teaching the mother about this condition. Which response from the mother indicates a need for further teaching? a) "I need to watch for pain, tenderness, or redness." b) "I can tape a quarter over the hernia to reduce it." c) "Incarceration is rare, but it can occur." d) "My son could have some appearance-related self-esteem issues."
"I can tape a quarter over the hernia to reduce it." The use of home remedies to reduce an umbilical hernia should be discouraged because of the risk of bowel strangulation. The mother needs to be aware that strangulation can occur, but it is rare with an umbilical hernia. Pain, tenderness, or redness indicates incarceration, which although rare with umbilical hernias, can occur. She needs to understand the signs of strangulation and understand that some children have self-esteem issues related to the large protrusion of the unrepaired umbilical hernia. Physical needs of the child have priority over any types of potential psychosocial issues. Self-esteem issues may arise due to a large protrusion of an unrepaired umbilical hernia.
The nurse is caring for a child who was involved in an automobile accident in which extensive damage to the small intestine occurred. A surgical resection of the small intestine resulted in massive small intestine loss, causing short bowel syndrome. The parents voice concern to the nurse that their child will "never be the same." What is the best response by the nurse?
"I can't imagine what you're going through. We will be here to support and educate you on your child's condition and treatments throughout their care." Being empathetic and reassuring the parents that the staff will be there to support them and educate them will provide some relief of anxiety since this is a chronic condition. Telling them their is nothing they could have done to prevent this from happening does not help the current situation. Giving hope is good, but giving possible false hope sets the family up for disappointment. Telling the family to be strong does not provide support.
The nurse has performed client teaching to 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 occurred?
"I have to be careful because I am prone to not absorbing nutrients." Crohn disease typically effects the small intestine more than the large intestine and it's onset is between the ages of 10 to 20 years. The cobblestone lesions in the small intestine prevents absorption of nutrients that normally occurs. The diarrhea is not directly related to the cobblestone lesions, and ulcerative colitis is characterized by the disease effecting the intestine(s) in a continuous pattern.
A nurse caring for Paulo, an infant born with a cleft palate, notices that the parents rarely interact with their child. The nurse overhears the mother telling her husband that she "feels like crying" every time she looks at their son. What would be the best response from the nurse? a) "Many infants are born with this condition. Your son's palate is not nearly as bad as some cases." b) "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?" c) "Your son needs you right now. You should put your negative feelings about his condition aside for his sake." d) "Keep in mind that your son'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 " The nurse should support the family's adjustment to a child'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.
The nurse is caring for an infant recently diagnoses with thrush and was 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." 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 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 nurse is providing instructions to the parents of a 10-year-old boy who has undergone a barium swallow/upper and lower GI for suspected inflammatory bowel disease. Which of the following instructions is most important? a) "Your child could have diarrhea for several days afterward." b) "Your child might have lighter stools for the next few days." c) "Please be aware of any signs of infection." d) "It is very important to drink lots of water and fluids after the test is finished."
"It is very important to drink lots of water and fluids after the test is finished."
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?
"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." 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
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? a) "There is gluten hidden in unexpected foods." b) "My daughter is eating more vegetables." c) "There are many types of flour besides wheat." d) "My daughter can eat any kind of fruit."
"My daughter can eat any kind of fruit."
A 3-day-old infant presenting with physiologic jaundice is hospitalized and placed under phototherapy. Which response indicates to the nurse that the parent needs more teaching? 1. "My infant is at risk for dehydration." 2. "My infant needs to stay under the lights, except during feeding time." 3. "My infant can continue to breastfeed during this time." 4. "My infant has a serious liver disease."
"My infant has a serious liver disease."
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? a) "Offer him some orange juice." b) "Encourage him to have some soda." c) "Try some Anbesol or Kank-A." d) "Offer 'magic mouthwash' followed by a popsicle."
"Offer 'magic mouthwash' followed by a popsicle."
The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac syndrome. The caregivers make the following statements. Which statement indicates a need for further teaching regarding the dietary restrictions for the child with celiac syndrome? a) "Even though milk and pudding are good for her, we don't give her those foods." b) "She loves hotdogs, and we always cut hers up into small pieces." c) "I have learned to make my own bread with no gluten." d) "The soup we eat at our house is all made from scratch."
"She loves hotdogs, and we always cut hers up into small pieces."
The nurse is collecting data on a 2 ½-year-old child admitted with a diagnosis of gastroenteritis. When interviewing the caregivers, which question is most important for the nurse to ask? a) "How many times a day does your child urinate?" b) "What foods has your child eaten during the last few days." c) "Tell me about the types of stools you child has been having." d) "How long has your child been toilet trained?"
"Tell me about the types of stools you child has been having." "Tell me about the types of stools you child has been having." 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 number and type of stools per day. Recent eating patterns, 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 physician recommends a gastrostomy for a 4-year-old client with an obstruction. The parents ask the certified wound, ostomy, and continence nurse (CWOCN) what the surgery entails. What is the nurse's best response? a) "The surgery is performed to create an opening between the esophagus and the neck." b) "The surgery will create an opening to the large intestine." c) "The surgery creates an opening between the stomach and abdominal wall." d) "The surgery will create an opening to the small intestine."
"The surgery creates an opening between the stomach and abdominal wall."
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? a) "Your child will be treated with oral iron preparations to correct the anemia." b) "The treatment for the disorder will be a surgical procedure." c) "We will give enemas until clear and then teach you how to do these at home." d) "Your child will receive counseling so the underlying concerns will be addressed."
"The treatment for the disorder will be a surgical procedure." 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.
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? a) "We might notice some of the medication in her stool" b) "She might lose some weight initially." c) "This drug helps to control the abdominal cramping." d) "We should not stop this medication abruptly."
"We should not stop this medication abruptly."
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? a) "You will most likely have a blood test to check for certain antibodies." b) "You will most likely have viral studies." c) "You will most likely be tested for ammonia levels." d) "You will most likely have an ultrasound evaluation."
"You will most likely have a blood test to check for certain antibodies."
Which client most likely has ulcerative colitis rather than Crohn disease? a) 14-year-old female with full-thickness chronic inflammation of the intestinal mucosa b) 18-year-old male with abdominal pain c) 16-year-old female with continuous distribution of disease in the colon, distal to proximal d) 12-year-old with oral temperature of 101.6° F (38.7° C)
16-year-old female with continuous distribution of disease in the colon, distal to proximal Ulcerative colitis is usually continuous through the colon while the distribution of Crohn disease is segmental. Crohn disease affects the full thickness of the intestine while ulcerative colitis is more superficial.
The child has been diagnosed with severe dehydration. The physician has ordered the nurse to administer a bolus of 20 mL/kg of normal saline over a 2-hour period. The child weighs 63.5 lb (28.8 kg). At which mL/hour should the nurse set the child's intravenous administration pump? Record your answer using a whole number.
289 The child weighs 63.5 pounds. 63.5 pounds x 1 kg/2.2 pounds = 577.2727 mL 577.2727 mL of normal saline/2 hours = 288.6364 mL Rounded to the nearest whole number = 289 mL/hour
The infant is listless with sunken fontanels and has been diagnosed with dehydration. The infant is still producing at least 1 mL/kg each hour of urine. The infant weighs 13.2 lb (6 kg). At the minimum, how many milliliters of urine will the infant produce during the next 8-hour shift? Record your answer using a whole number. ____________mL
48 mL
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 which time frame? a) 7 to 14 days b) 3 to 5 days c) 1 to 3 days d) 5 to 7 days
7 to 14 days
The nurse is conducting a physical examination of an 18-month-old with suspected intussusception. Which finding would the nurse identify as the hallmark of this condition? a) Skin tenting b) Perianal skin tags c) Abdominal pain and guarding d) A sausage-shaped mass in the upper midabdomen
A sausage-shaped mass in the upper midabdomen
A mother brings her 3-year-old son to the ER and tells the triage nurse that he has been vomiting blood. A medical history determines that the 3-year-old has no history of GI disturbances and his only symptoms are a slightly elevated fever and vomiting bright red blood. Based on these symptoms, what condition might the nurse suspect? a) Acute upper GI bleeding b) GI tract obstruction c) Intussusception d) Gastroesophageal reflux
Acute upper GI bleeding
The nurse is to obtain a stool specimen from a 4-year-old child who has very liquid stool. The child is ambulatory but weak. Which collection method would be most effective for the nurse to use?
Apply a urine bag to the anal area. With very liquid stool, applying a urine bag to the anal area is most effective in collecting the specimen. Using a tongue blade to scrape a specimen from a diaper would be appropriate if the stool is formed. However, putting a diaper on a 4-year-old would be demeaning. Defecating into a collection container that sits at the back of the toilet would be more appropriate for an older child who is ambulatory. A bedpan would be appropriate if the child was bedridden.
The nurse observes the interactions of parents with their infant who was born with a cleft lip. The mother is attempting to feed the baby, but does not make eye contact. The father is watching television with his back turned to the mother and baby. What psychosocial nursing intervention would be most helpful to this family? a) Explain to the parents that surgical intervention will fix the defect in the baby's lip. b) Ask the parents if they have any questions regarding the care of their child. c) Teach the mother the appropriate technique for breast-feeding an infant with cleft lip. d) Refer the family to a social worker or mental health practitioner.
Ask the parents if they have any questions regarding the care of their child.
The nurse is caring for a child who has had diarrhea and vomiting for the past several days. What is the priority nursing assessment? 1. Determine the child's weight 2. Ask if the family has traveled outside of the country 3. Assess circulation and perfusion 4. Send a stool specimen to the lab
Assess circulation and perfusion
The nurse is doing dietary teaching with the caregivers of a child diagnosed with idiopathic celiac disease. Of the following foods, which would most likely be appropriate in the child's diet? a) Potatoes b) Toast c) Oatmeal d) Bananas
Bananas The young child should be started on a starch-free, low-fat diet. Bananas contain invert sugar and are usually well tolerated. Products that contain wheat, rye, or oats should be excluded.
A child is diagnosed with intussusception. The nurse anticipates that what action would be attempted first to reduce this condition? a) Endoscopic retrograde cholangiopancreatography b) Surgery c) Barium enema d) Upper endoscopy
Barium enema 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 taking a health history of a 2-year-old girl presenting with a sudden onset of severe vomiting. Which description would suggest an obstruction? a) Bloody vomiting b) Effortless vomiting c) Bilious vomiting d) Projectile vomiting
Bilious vomiting
A child is scheduled for a urea breath test. The nurse understands that this test is being performed for which reason? a) Determine esophageal contractility b) Detect Helicobacter pylori c) Evaluate gastric pH d) Confirm pancreatitis
Detect Helicobacter pylori a rapid diagnostic procedure used to identify infections by Helicobacter pylori, a spiral bacterium implicated in gastritis, gastric ulcer, and peptic ulcer disease. It is based upon the ability of H. pylori to convert urea to ammonia and carbon dioxide.
The nurse is caring for a child admitted with gastroesophageal reflux (GER). Which clinical manifestation would likely be seen in this child? a) Bouts of diarrhea with failure to gain weight b) Effortless vomiting just after the child has eaten c) Forceful vomiting followed by the child being eager to eat again d) Severe constipation with occasional ribbon-like stools
Effortless vomiting just after the child has eaten Almost immediately after feeding, the child with gastroesophageal reflux vomits the contents of the stomach. The vomiting is effortless, not projectile in nature.
A preschooler has celiac disease. Her mother is preparing a gluten-free diet. By preparing which breakfast foods would you believe she understands the diet? a) Rye toast and peanut butter b) Eggs and orange juice c) Cheerios (oat cereal) and skim milk d) Wheat toast and grape jelly
Eggs and orange juice
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 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? a) Pyloric stenosis b) Cleft palate c) Esophageal atresia (EA) d) Hernia
Esophageal atresia (EA) A maternal history of polyhydramnios is usually present in one-third of cases of EA and in some cases of tracheoesophageal fistula (TEF).
Inguinal hernia usually occurs in girls. a) True b) False
False
The pH of blood is normally slightly acidic, ranging from 6.85 to 6.95. a) True b) False
False
A mother brings her 6-month-old infant to the clinic. The child has been vomiting since early morning and has had diarrhea since the day before. His temperature is 38C, pulse 140, and respiratory rate 38. He has lost 6oz since his well-child vist 4 days ago. He cries before passing a bowel movement. He will not breastfeed today. What is the priority? 1. Thermoregulation alteration 2. Pain (abdominal) related to diarrhea 3. Fluid volume deficit related to excess losses and inadequate intake 4. Alteration in nutrition, less than body requirements, related to decreased oral intake
Fluid volume deficit related to excess losses and inadequate intake
The nurse has admitted a child with a diagnosis of severe gastroenteritis. To help prevent the risk of transmitting infection to other patients, the nurse should a) Follow standard precautions b) Discourage anyone from visiting c) Sterilize thermometers between patients d) Wear a mask when handling articles contaminated with feces
Follow standard precautions
The nurse is collecting data on a child who has been brought to the clinic. The child has urticaria, pruritus, stomach pains, and respiratory symptoms. The nurse recognizes that the clinical manifestations noted in this child are commonly seen in which of the following disorders? a) Vitamin deficiency b) Food allergies c) Protein malnutrition d) Calcium insufficiency
Food allergies
A father brings Jacob, age 2, to the health clinic with complaints of diarrhea, vomiting, and abdominal pain. The father tells the nurse that he is a single parent and Jacob is enrolled in a local daycare center. Based on this information, what gastrointestinal condition might the nurse suspect? a) Appendicitis b) Gastroenteritis c) Pancreatitis d) Hirschsprung disease
Gastroenteritis
The nurse is conducting a physical examination of an infant with suspected pyloric stenosis. Which finding indicates pyloric stenosis? a) Sausage-shaped mass in the upper mid abdomen b) Perianal fissures and skin tags c) Abdominal pain and irritability d) Hard, moveable "olive-like mass" in the upper right quadrant
Hard, moveable "olive-like mass" in the upper right quadrant 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 2-month-old boy is admitted to the emergency room with severe diarrhea. Intravenous fluid is prescribed for him. Before adding potassium to this solution, which assessment would you record? a) He "attunes" to a music box. b) He has voided. c) His hands are restrained. d) He cries with tears.
He has voided.
An adolescent boy is diagnosed with hepatitis A. Which problem should be considered when planning care? a) He will become fatigued easily. b) His urine will be dark and infectious. c) Hypothermia is common. d) He will be very irritable and perhaps require sedation.
He will become fatigued easily.
A nurse prepares a menu for a client with Crohn disease. What is the focus of dietary management for this disease? a) Low calorie, high carbohydrate b) High carbohydrate, high protein c) High calorie, high fiber d) Low fiber, low calorie
High carbohydrate, high protein
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? a) Short bowel syndrome (SBS) b) Hirschsprung disease c) Gastroenteritis d) Ulcerative colitis (UC)
Hirschsprung disease 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 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? a) Maintaining skin integrity b) Promoting comfort c) Improving hydration d) Preparing family for home care
Improving hydration 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?
In this disorder the sphincter that leads into the stomach is relaxed. 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? a) Necrotizing enterocolitis b) Intussusception c) Volvulus with malrotation d) Short-bowel/short-gut syndrome
Intussusception
A 10-year-old girl with an intestinal virus has been vomiting and has become dehydrated. She says she is mildly thirsty, her skin turgor is poor, and her skin is dry and cool. Her serum sodium level is normal. The nurse recognizes that she has which type of dehydration? a) Isotonic b) Acidotic c) Hypotonic d) Hypertonic
Isotonic Signs and symptoms of isotonic dehydration include the following: mild thirst; poor skin turgor; dry, cool skin; decreased urine output; irritability; and a normal sodium level. Signs and symptoms of hypotonic dehydration include the following: moderate thirst; very poor skin turgor; clammy, cool skin; decreased urine output; lethargy; and a reduced sodium level. Signs and symptoms of hypertonic dehydration include the following: extreme thirst; moderate skin turgor; warm skin; decreased urine output; extreme lethargy; and an increased sodium level. Acidotic is not a type of dehydration.
A nurse reads the medical history of a client who is scheduled for a hernia repair that is termed "reducible." What best describes this type of hernia? a) Its contents can be easily manipulated back into the peritoneal cavity. b) Intestinal obstruction and ischemia may occur. c) The abdominal contents have become trapped. d) The herniated intestines are twisted and edematous.
Its contents can be easily manipulated back into the peritoneal cavity. A hernia in the abdominal region is considered reducible when its contents are easily manipulated back into the peritoneal cavity. An incarcerated hernia occurs when the abdominal contents become trapped and difficult to reduce. A strangulated hernia occurs when the herniated intestines become twisted and edematous compromising blood flow. Intestinal obstruction and ischemia may occur
A father brings his 10-year-old daughter in to the physician's office with jaundice, headache, fever, and anorexia, symptoms she has had for the past few days. The nurse should suspect infection of which organ in this client? a) Stomach b) Small intestines c) Esophagus d) Liver
Liver No matter which virus is involved, hepatitis is a generalized body infection with specific intense liver effects. Type A occurs in children of all ages and accounts for approximately 30% of instances. With hepatitis A, children notice headache, fever, and anorexia. Jaundice occurs as liver function slows
The parents of a 6-month-old have brought their child to the emergency department with vomiting and diarrhea for the past 3 days. The report the child as being very lethargic today. During the assessment the nurse notes decreased skin turgor, delayed capillary refill, and pale, slightly dry skin. Based on the objective and subjective data, what does the nurse determine the child to be?
Moderately dehydrated In addition to these signs and symptoms, signs and symptoms of moderate dehydration also include sunken fontanels, mildly sunken orbits, and urine output
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? a) History of hypoxia at birth b) Preterm birth c) Maternal use of acetaminophen in third trimester d) Mother age 42 with pregnancy
Mother age 42 with pregnancy
A mother calls the doctor's office and tells the nurse that she is concerned because her 4-month-old keeps "spitting up" with every feeding. What would indicate that the child is regurgitating as opposed to vomiting?
Only occurs with feeding Regurgitation typically occurs only with feeding, runs out of the mouth with little force, smells barely sour and is only slightly curdled, appears to cause no pain or distress, occurs only once per feeding, and amounts to only about 1 to 2 tsp. Vomiting may occur at times other than feeding, is forceful and is typically projected 1 ft or more away from infant, is extremely sour smelling and curdled, is typically accompanied by crying, continues until the stomach is empty, and amounts to the full stomach contents.
The nurse caring for an 18-month-old infant with Meckel diverticulum knows that the most common clinical manifestation of this condition is: a) Dehydration b) Painless rectal bleeding c) Respiratory distress d) Ischemia
Painless rectal bleeding With Meckel diverticulum, most symptomatic children present younger than age 2 years. Intermittent, painless rectal bleeding is the most common clinical manifestation of Meckel diverticulum. The blood is most often bright red or maroon and may be passed independent of stool due to ulceration at the junction of the ectopic tissue and the normal ileal mucosa.
A mother brings her 10-year-old son to the ER with complaints 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 consider as a diagnosis? a) Crohn disease b) Appendicitis c) Ulcerative colitis d) Pancreatitis
Pancreatitis pancreatitis typically has a complaint of abdominal pain, either epigastric, upper left, or upper right quadrant pain that may radiate to the back. 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.
he nurse is examining a 7-year-old with suspected appendicitis. Which physical findings would indicate the possibility of appendicitis? a) Tenderness that comes and goes in the lower abdomen b) Persistent, right lower quadrant pain with rebound tenderness c) Intermittent, left lower quadrant pain with rebound tenderness d) Diffuse, intermittent abdominal pain
Persistent, right lower quadrant pain with rebound tenderness
A 3-month-old infant presents with a history of vomiting after feeding. The plan for the infant is to rule out GER. What information from the history would lead the nurse to believe that this infant may need further intervention? 1. Poor weight gain 2. Has small "spits" after feeding 3. Sleeps through the night 4. Is difficult to burp
Poor weight gain
A 12-year-old boy has just undergone a liver transplantation and is recovering. After performing a finger stick puncture and assessing the results, the nurse administers a 10% solution of dextrose IV. What is the correct rationale for this intervention?
Prevention of hypoglycemia Hypoglycemia is a major danger following liver transplantation because glucose levels are regulated by the liver, and the transplanted organ may not function efficiently at first. Assess serum glucose levels hourly by finger stick puncture. A 10% solution of dextrose IV may be necessary to prevent hypoglycemia. Careful tissue matching before the transplantation is needed to reduce the possibility of stimulating T-cell rejection. Sodium, potassium, chloride, and calcium levels are evaluated approximately every 6 to 8 hours to be certain electrolyte balance is maintained, but potassium is rarely added to IV solutions because of the risk that renal failure has occurred. IV therapy with hypotensive agents such as hydralazine (Apresoline) and nitroprusside may be needed to reduce hypertension
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? a) Frequent urination b) Projectile vomiting c) Explosive diarrhea d) Severe abdominal pain
Projectile vomiting
A mother is alarmed because her 6-week-old boy has begun vomiting almost immediately after every feeding. In the past week, the vomiting has grown more forceful, with the vomit projecting several feet from his mouth. He is always hungry again just after vomiting. At the physician's office, the nurse holds the child and gives him a bottle of water. While he drinks, she notes an olive-size lump in his right abdomen. Which condition should the nurse suspect in this child? a) Gastroesophageal reflux b) Appendicitis c) Pyloric stenosis d) Peptic ulcer disease
Pyloric stenosis
A child presents with a 2-day history of fever, abdominal pain, occasional vomiting, and decreased oral intake. Which finding would the nurse prioritize for immediate reporting to the physician? 1. Temperature 101.9F 2. Rebound tenderness and abdominal guarding 3. Parents will be leaving the child alone in the hospital 4. Child can tolerate only sips of fluid without nausea
Rebound tenderness and abdominal guarding
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 his stools. The clinical manifestation this caregiver is describing is:
Steatorrhea. Steatorrhea (fatty stools) is a classic symptom of celiac disease. Currant jelly stools are a sign of intussusception. Projectile vomiting is a sign of pyloric stenosis.
If an adolescent has hepatitis B, what would be an important nursing action? a) Strict enforcement of standard precautions b) Conscientious collection of stool for ova and parasites c) Close observation to detect cerebral hallucinations d) Strict calculation of caloric and vitamin B intake
Strict enforcement of standard precautions
The nurse is caring for a 6-month-old infant who was admitted to the emergency room 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? a) Feed the child a cracker b) Take a stool culture c) Administer antibiotic therapy d) Administer IV potassium
Take a stool culture
The nurse is assessing a 10-day-old infant for dehydration. Which finding indicates severe dehydration?
Tenting of skin Tenting of skin is an indicator of severe dehydration. Soft and flat fontanels 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.
Which of the following is most correct regarding the gastrointestinal system of the child? a) The child's gastrointestinal system is fully matured when the child is born. b) The enzymes secreted by the child's liver and pancreas are much greater in amount than in the adult. c) The child cannot break down and use complex carbohydrates in the same way the adult can. d) The speed with which food passes through the gastrointestinal tract in the child is much slower than in the adult.
The child cannot break down and use complex carbohydrates in the same way the adult can.
The nurse is caring for a 6-month-old girl with diarrhea and dehydration. The mother is concerned because the girl has some patches on her tongue. Which feature indicates a geographic tongue rather than thrush? a) The patches are thick, white plaques on the tongue. b) The patches are light in color on the tongue. c) There are white patches on the erupted teeth. d) There are plaques on the buccal mucosa.
The patches are light in color on the tongue.
In understanding the gastrointestinal system, the nurse recognizes that this system includes the stomach and intestines as well as: a) The pharynx and esopagus b) Nerves throughout the abdomen c) The brain and spinal cord d) A protective cushion lining the organs
The pharynx and esophagus The main organs of the gastrointestinal (GI) or digestive system are the mouth, pharynx (throat), esophagus, stomach, small intestine, large intestine, rectum, and anal canal. The brain, spinal column, and nerves are part of the nervous system, and there is a protective coating surrounding the nerves.
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 colic? a) In this disorder the sphincter that leads into the stomach is relaxed. b) A thickened, elongated muscle causes an obstruction at the end of the stomach. c) There are recurrent paroxysmal bouts of abdominal pain. d) A partial or complete intestinal obstruction occurs.
There are recurrent paroxysmal bouts of abdominal pain.
Constipation may be initially caused by psychological problems.
True Some children begin holding stool for psychological reasons. Once the process begins, however, the hardened stool, the anal fissures, and the pain on defecation soon occur, and what began for an emotional reason becomes a physical ailment. This is important to understand, because with these children, therapy involves both counseling to correct the initial problem and treatment of the physical symptoms
A 6-month-old boy is diagnosed with pyloric stenosis. When you take a health history from his mother, which symptom would you expect to hear her describe? a) Vomiting immediately after feeding b) Vomiting about 2 hours after feeding c) Refusal to eat d) Chronic diarrhea
Vomiting immediately after feeding
Noah is an 18-month-old who is brought to the ER with flu-like symptoms. He 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: a) cystic fibrosis. b) Hirschsprung disease. c) inflammatory bowel disease. d) gastroesophageal reflux disease.
gastroesophageal reflux disease. The child with gastroesophageal reflux disease may present with the physical findings of pneumonia secondary to aspiration of refluxed stomach contents.
In caring for an infant diagnosed with pyloric stenosis, the nurse would anticipate that she would: a) prepare the infant for surgery. b) assist in doing a barium enema procedure on the infant. c) medicate the infant with analgesics. d) change the infant's diet to lactose-free.
prepare the infant for surgery. A surgical procedure called a pyloromyotomy (also known as a Fredet-Ramstedt operation) is the treatment of choice for pyloric stenosis.
You care for a 12-year-old girl with Crohn disease. A primary assessment you would want to make when caring for her would be to note if: a) she has a temperature. b) her joints are not swollen. c) she has a headache. d) lung sounds are clear.
she has a temperature.
The nurse is working with the mother of a toddler experiencing constipation. What information regarding childhood constipation should the nurse share with the mother?
• "Have your son sit on the toilet twice a day, after breakfast and dinner, for 5 to 15 minutes." • "If your child has a fecal impaction, you can give him an enema." • "Reward your child for sitting on the toilet as asked, not just when they have a bowel movement." Proper education for constipation in children includes educating the families about the importance of compliance with medication use. Many children present to their physician or nurse practitioner with fecal impaction or partial impaction. Teach parents how to disimpact their children at home; this often requires an enema or stimulation therapy. To facilitate daily bowel evacuation, the child should sit on the toilet twice a day (after breakfast and dinner) for 5 to 15 minutes. Instruct the family to keep a "star" or reward chart to encourage compliance. Parents should award the star for compliance with time sitting on the toilet and should not reserve rewards for successful bowel movements only.
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. a) Steatorrhea b) Sunken abdomen c) Polycythemia d) Constipation e) Failure to thrive f) Diarrhea
• Constipation • Diarrhea • Failure to thrive • Steatorrhea
A child with cirrhosis of the liver is admitted to the acute care facility in preparation for a liver transplant. When completing the physical examination, what would the nurse expect to assess? Select all that apply. a) Spider angiomas b) Fatty stools c) Facial erythema d) Jaundice e) Ascites
• Jaundice • Ascites • Spider angiomas Assessment findings associated with cirrhosis include jaundice, ascites, spider angiomas, and palmar erythema. Fatty stools are associated with celiac disease.
The nurse is developing a teaching plan for the parents of an 11-month-old infant with gastroesophageal reflux disease (GERD). The child will be managed medically. What actions would the nurse incorporate into the teaching plan? Select all that apply. a) Burping the infant at the end of the feeding b) Giving the child small frequent feedings c) Thinning the formula with water to ease flow d) Keeping the child upright for 30 minutes after feeding e) Administering prokinetics to empty the stomach quickly
• Keeping the child upright for 30 minutes after feeding • Giving the child small frequent feedings • Administering prokinetics to empty the stomach quickly
12-year-old Hilary is brought to the emergency room by her parents with severe abdominal pain. The nurse performs a physical assessment to check for appendicitis. Which assessment parameters indicate appendicitis? Select all that apply. a) Normal to hyperactive bowel sounds early b) Rebound tenderness present with palpation in the left upper quadrant c) Distended abdomen with unperforated appendicitis d) Hypoactive bowel sounds with perforation e) Low-grade fever, nausea, anorexia, and vomiting f) Irritation and pain in the right lower quadrant
• Normal to hyperactive bowel sounds early • Hypoactive bowel sounds with perforation • Irritation and pain in the right lower quadrant • Low-grade fever, nausea, anorexia, and vomiting
The nurse is positioning an infant who has just had his left-sided cleft lip repaired. What positions are acceptable for this infant? Select all that apply. a) Right side lying b) Left side lying c) Supine d) Prone e) High fowlers
• Right side lying • Supine
The nurse caring for a patient with Crohn disease knows that long-term complications for this patient might include (select all that apply): a) Fistula b) Gallstones c) Pancreatitis d) Short-bowel syndrome e) Stricture f) Intra-abdominal abscess formation
• Stricture • Fistula • Intra-abdominal abscess formation • Short-bowel syndrome Long-term complications may include stricture, fistula, and intra-abdominal abscess formation. Individuals with severe disease who require extensive resection of diseased bowel may be left with short bowel syndrome and long-term dependence on PN.
